Outlay and Request for Reimbursement for Construction Programs

OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT
FOR CONSTRUCTION PROGRAMS
(See instructions on back)

OMB APPROVAL NO. 0348-0002
1. TYPE OF REQUEST

PAGE

OF
PAGES

2. BASIS OF REQUEST

FINAL

PARTIAL

CASH

ACCRUAL

3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL
ELEMENT TO WHICH THIS REPORT IS SUBMITTED

4. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER 5. PARTIAL PAYMENT REQUEST NO.
ASSIGNED BY FEDERAL AGENCY

6. EMPLOYER IDENTIFICATION
NUMBER

FROM (Month, day, year)

7. RECIPIENT'S ACCOUNT NUMBER
OR IDENTIFYING NUMBER

PERIOD COVERED BY THIS REQUEST
TO (Month, day, year)

9. RECIPIENT ORGANIZATION

10. PAYEE (Where check is to be sent if different than item 9)

Name:

Name:

No. and Street:

No. and Street:

City, State and
ZIP Code:

City, State and
ZIP Code:
STATUS OF FUNDS

11.
PROGRAMS
CLASSIFICATION
a. Administrative expense

FUNCTIONS

ACTIVITIES

TOTAL

(a)

(b)

(c)

$

$

$

$

$

$

$

$

b. Preliminary expense
c. Land, structures, right-of-way
d. Architectural engineering basic fees
e. Other architectural engineering fee
f. Project inspection fees
g. Land development
h. Relocation expense
i. Relocation payments to individuals
and businesses
j. Demolition and removal
k. Construction and project improvement cost
l. Equipment
m. Miscellaneous cost
n. Total cumulative to date (sum of lines a thru m)
o. Deductions for program income
p. Net cumulative to date (line n minus line o)
q. Federal share to date
r. Rehabilitation grants (100% reimbursement)
s. Total Federal share (sum of lines q and r)
t. Federal payments previously requested
u. Amount requested for reimbursement
v. Percentage of physical completion of project

%

12. CERTIFICATION
I certify that to the best of my knowledge and
belief the billed costs or disbursements are
in accordance with the terms of the project
and that the reimbursement represents the
Federal share due which has not been
previously requested and that an inspection
has been performed and all work is in
accordance with the terms of the award.

AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION USABLE
271-103

a. RECIPIENT

b. REPRESENTATIVE
CERTIFYING TO LINE 11V

%

%

%

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE REPORT SUBMITTED

TYPED OR PRINTED NAME AND TITLE

TELEPHONE (Area code,
number, and extension)

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE SIGNED

TYPED OR PRINTED NAME AND TITLE

TELEPHONE (Area code,
number, and extension)
STANDARD FORM 271 (Rev. 7-97)

Prescribed by OMB Circular A-102 and A-110

INSTRUCTIONS
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the
Office of Management and Budget, Paperwork Reduction Project (0348-0004), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

Please type or print legibly. Items 3, 4, 5, 8, 9, 10, 11s and 11v are self explanatory; specific instructions for other items are as
follows:
Item

Entry

1 Mark the appropriate box. If the request is final, the
amounts billed should represent the final cost of the project.
2 Show whether amounts are computed on an accrued
expenditure or cash disbursement basis.
6 Enter the Employer Identification Number (EIN) assigned by
the U.S. Internal Revenue Service or FICE (institution) code
if requested by the Federal agency.
7 This space is reserved for an account number or other
identifying number that may be assigned by the recipient.
11 The purpose of vertical columns (a) through (c) is to provide
space for separate cost breakdowns when a large project
has been planned and budgeted by program, function or
activity. If additional columns are needed, use as many
additional forms as needed and indicate page number in
space provided in upper right; however, the summary totals
of all programs, functions, or activities should be shown in
the "total" column on the first page. All amounts are
reported on a cumulative basis.
11a Enter amounts expended for such items as travel, legal
fees, rental of vehicles and any other administrative
expenses. Include the amount of interest expense when
authorized by program legislation. Also show the amount of
interest expense on a separate sheet.
11b Enter amounts pertaining to the work of locating and
designing, making surveys and maps, sinking test holes,
and all other work required prior to actual construction.
11c Enter all amounts directly associated with the acquisition of
land, existing structures and related right-of-way.
11d Enter basic fees for services of architectural engineers.
11e Enter other architectural engineering services. Do not
include any amounts shown on line d.
11f Enter inspection and audit fees of construction and related
programs.
11g Enter all amounts associated with the development of land
where the primary purpose of the grant is land
improvement. The amount pertaining to land development
normally associated with major construction should be
excluded from this category and entered on line k.
11h Enter the dollar amounts used to provide relocation advisory
assistance and net costs of replacement housing (last
resort). Do not include amounts needed for relocation
administrative expenses; these amounts should be included
in amounts shown on line a.
11i Enter the amount of relocation payments made by the
recipient to displaced persons, farms, business concerns,
and nonprofit organizations.

Item

Entry

11j Enter gross salaries and wages of employees of the
recipient and payments to third party contractors directly
engaged in performing demolition or removal of structures
from developed land. All proceeds from the sale of salvage
or the removal of structures should be credited to this
account; thereby reflecting net amounts if required by the
Federal agency.
11k Enter those amounts associated with the actual
construction of, addition to, or restoration of a facility. Also,
include in this category, the amounts for project
improvements such as sewers, streets, landscaping, and
lighting.
11l Enter amounts for all equipment, both fixed and movable,
exclusive of equipment used for construction. For
example, permanently attached laboratory tables, built-in
audio visual systems, movable desks, chairs, and
laboratory equipment.
11m Enter the amounts of all items not specifically mentioned
above.
11n Enter the total cumulative amount to date which should be
the sum of lines a through m.
11o Enter the total amount of program income applied to the
grant or contract agreement except income included on
line j. Identify on a separate sheet of paper the sources
and types of the income.
11p Enter the net cumulative amount to date which should be
the amount shown on line n minus the amount on line o.
11q Enter the Federal share of the amount shown on line p.
11r Enter the amount of rehabilitation grant payments made to
individuals when program legislation provides 100 percent
payment by the Federal agency.
11t Enter the total amount of Federal payments previously
requested, if this form is used for requesting
reimbursement.
11u Enter the amount now being requested for reimbursement.
This amount should be the difference between the
amounts shown on lines s and t. If different, explain on a
separate sheet.
12a To be completed by the official recipient official who is
responsible for the operation of the program. The date
should be the actual date the form is submitted to the
Federal agency.
12b To be completed by the official representative who is
certifying to the percent of project completion as provided
for in the terms of the grant or agreement.

STANDARD FORM 271 (Rev. 7-97) Back