Requisition for Economic Development Funds

Part 1: Grant Summary
1. Name and Address of Grantee: / 2. Name and telephone number of the person to contact if there are questions about this requisition: / 3. Grantee Number:
4. Grantee Tax ID Number:
* Person to whom check should be mailed: / Telephone No. /
  1. Requisition Number:

6. Amount of funds requested:
7. Project Number /

E-1

/

TOTAL

8. CDBG funds received to date
9. Program income received to date
10. Subtotal (line 8 + line 9)
11. CDBG expenditures to date
12. CDBG funds needed
13. CDBG funds on hand (line 10 - line 11)
14. Amount of funds requested (line 12 - line 13)
15. CERTIFICATION
I certify that the data presented in this requisition is correct, that this requisition is in accordance with the terms and conditions of the above referenced grant and that the amount requested is not in excess of current needs.
______
Date Authorized Signature Title
______
Date Authorized Signature Title
FOR DCA USE ONLY
______
Date Received
______
Date of Check
______
Check Number
______
Date Mailed / Explanation of Changes:
______
Reviewed by Date Approved by Date

CDBG # 103 (02-2007)

Requisition for Economic Development Funds

Part II: Project Expenditure Report

1. Name of Recipient / 3. Project Number
2. Grant Number / 4. Project Name
5. ACTIVITY / 6. BUDGET AMOUNT / 7. CDBG EXPENDITURES TO DATE / 8. PROJECT COST THIS REQUISITION / 9. SERVICE DELIVERY COST THIS REQUISITION / 10.PROJECTED EXPENDITURES THIS REQUISITION
a. Acquisition / $ / $ / $ / $ / $
b. Disposition
c. Public facilities and improvements
(1) Senior and handicapped centers
(2) Solid waste disposal facilities
(3) Parks, playgrounds and recreation facilities
(4) Neighborhood facilities
(5) Fire protection facilities and equipment
(6) Parking facilities
(7) Public Utilities, other than water and sewer
(8) Water and Sewer Improvements
1987)
(9) Street Improvements
(10) Flood and drainage improvements
(11) Pedestrian improvements
(12) Other public facilities
(13) Sewer
(14) Water
d. Clearance activities
e. Public Services
f. Relocation assistance
g. Construction, rehabilitation and preservation activities
(1) Construction or rehabilitation of commercial and industrial buildings
(2) Rehabilitation of privately owned dwellings
(3) Rehabilitation of publicly owned dwellings
(4) Code enforcement
(5) Historic preservation
h. Development financing
(1) Working Capital
(2) Machinery and equipment
i. Removal of architectural barriers
j. Other activities – (TOTAL amount of other activities)
k. SUBTOTAL
l. Planning
m. Administration
n. TOTAL

INSTUCTIONS FOR PREPARING REQUISTIONS FOR FUNDS

General Filing Requirements

Grantees are provided with a two-part form to complete. Two copies (one copy if faxed) of each Requisition should be forwarded to the CommerceFinanceCenter.

Part I: Grant Summary includes summary information about prior requisitions and expenditures for the entire grant. This form is completed one for each requisition.

Part II: Project Expenditure reflects detailed expenditure information by project. Grantees with multiple projects must complete a separated copy of this form for each project under a particular grant.

PARTI: GRANT SUMMARY

Block 1.The name and address of the recipient is entered in this block.

Block 2. The name and telephone number of the person who can best answer questions concerning the submitted requisition(s) is entered in this block.

Block 3.The Grant number is entered in this block.

Block 4.The Grantee’s Federal Tax ID number may be entered in this block.

Block 5.Requisitions against each grant must be numbered consecutively beginning with number one (1) and shown in this block.

Block 6.This block should reflect the total funds requested for all projects (E-1)

Block 7.ED project numbers are shown in separate columns for each project for which funds are requested.

Block 8.The cumulative amount of funds received to date for each project should be shown in this block(s). The total amount of funds received for all projects under the grant should be listed in the Total column.

Block 9.Program income (if applicable) received to date by project should be entered in this block. Program income for each project should be added together and listed in the Total column.

Block 10.The Subtotal in this line is obtained by adding Blocks 7 and 8.

Block 11.These figures should reflect, by project, the program income and grant funds actually spent and disbursed by the recipient. Grant Recipient funds (if applicable) used on a reimbursement basis should not be shown in this line. This entry should be equal to the amount shown in Part II, column 7, line N.

Block 12.This amount reflects, by project, the total amount of funds needed to meet expenditures. This entry should equal the amount shown in Part II, column 8, line N.

Block 13.This amount reflects actual cash on hand (if applicable) for each project, and is obtained by subtracting the amount shown in line 11 from line 10.

Block 14.Total amount of funds requested, by project, is calculated by subtracting line 13 from line 12.

Block 15.Two signatures are required on each requisition. Only authorized persons shown on the Signatory Form and Certification will be accepted by DCA. Signatures will be checked on each requisition for authenticity.

PART II: PROJECT EXPENDITURE REPORT

A separate Project Expenditure Report must be completed for each project for which funds are requisitioned.

Block 1.Indicated the name of the grant recipient.

Block 2.Enter ED Grant Number.

Block 3.Enter the ED Project Number for the project (E-1).

Block 4.Project Name, as shown in the application, is entered in this block.

Block 5.No entry necessary.

Column 6.The budgeted amount is shown for each approved activity in this column with a Subtotal shown in Line K and the Total shown in Line N.

Column 7.Expenditures are expenditures for which the recipient has used actual grant funds to pay costs. Grant recipient funds used on a reimbursement basis (if applicable) should not be shown in this column. Expenditures to date for each activity should be shown in this column with a Subtotal in Line K and Total in Line N. The total ofLine N of Column 7 should be the same as the number in Line 11 of Part I: Grant Summary.

Column 8.Project Cost is the actual cost of an activity (for example – materials, labor, supplies, housing units, building, land, removal of debris, permits, closing cost, site improvements, etc.).

Column 9.Service Delivery Cost is the actual cost to administer service to the activity – (for example – work-writeups, inspections, travel, etc.).

Column 10.Indicate the use of Funds Requested (as shown in Part I, Line 12) by budget line item for this project. Funds included in this column should include reimbursed costs, project cost, service delivery cost and projected expenditures for which grant funds are requested. A Subtotal should be shown in Line K and a Total in Line N. Line N of Column 10 should reflect the same amount as that in Part 1, Block 12.