Form 190-F-04-001 U.S. EPA PAYMENT REQUEST

United States
ENVIRONMENTAL PROTECTION AGENCY

OMB Control No. 2030-0020
Approval expires 06/30/2017

U.S. EPA PAYMENT REQUEST
Recipient Name:

Contact Person:

Fax #:

Phone #:
Email address:

EFT #

Request #

Assistance Agreement

Cash on Hand: $

Account No/Activity Code
(Superfund Site Specific)

$ Amount

Mark
(X) if
Credit

For EPA Internal Use Only

TOTAL AMOUNT REQUESTED $
I certify that to the best of my knowledge and belief the data above are correct
and that all outlays were made in accordance with the grant conditions or other
agreement and that payment is due and has not been previously requested.
APPROVALS:

Recipient Approving Official’s Signature

Date Approved

EPA Certifying Officer Approval

Date Approved

EPA 190-F-04-001

$

EPA APPROVED AMOUNT
For EPA Use Only

The public reporting and recordkeeping burden for this collection of information is estimated to average 30 minutes per response. Send comments on the Agency's need for this information, the accuracy of the provided
burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.