Grant Close-Out Certification Form

Grant Close-Out Certification Form

DCNR-2012-Dev
Dev-Form – 5 Rev. 3-12 / COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF CONSERVATION AND NATURAL RESOURCES
BUREAU OF RECREATION AND CONSERVATION
Parks, Recreation & Conservation Grants /

GRANT CLOSE-OUT CERTIFICATION FORM

Awards of $100,000 or more

INSTRUCTIONS
1.Complete Section I – Grantee and Project Identification
2.Complete Section II – Payment History
3.Complete Section III – Project Certification. Please sign, indicate title, and date form.
4.Submit the completed form to the address below and keep a copy for your records:
Department of Conservation & Natural Resources
Bureau of Recreation and Conservation
400 Market Street, 6th Floor
Harrisburg, PA 17101-2301
Fax: 717-787-9577
SECTION I - GRANTEE AND PROJECT IDENTIFICATION
Grantee:
E.I.N.: / DCNR Project Number: BRC-OPD-
Project Title:
County: / SAP GR Number:
SAP Vendor Number:
SECTION II - Payment History
Type of Close-Out Being RequestedPayment History
(check appropriate box)
Grant Amount$
Zero Payment Due Grantee
Less Previous Payment$
RefundDueCommonwealth
Total Project Expenditure$
Interest Earned$
If Total Project Expenditure is less than Previous Payment, indicate Refund due Commonwealth$
DCNR-2012-Dev
Dev-Form – 5 Rev. 3-12 / COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF CONSERVATION AND NATURAL RESOURCES
BUREAU OF RECREATION AND CONSERVATION
Parks, Recreation & Conservation Grants /

GRANT CLOSE-OUT CERTIFICATION FORM

Awards of $100,000 or more

SECTION III - PROJECT CERTIFICATION
I certify to the best of my knowledge that the above information provided on this form and related attachments is true, correct, and that:
1. The project was completed in accordance with the Grant Agreement.
  1. All project documentation will be kept on file for future auditing purposes for 3years from the date of the audit, and copies of the invoices and/or certificates for payment, cancelled checks, change orders, etc. will be furnished for review and inspection upon receipt of a request from the Department.
  2. Two copies of the financial compliance audit report prepared by an independent, licensed certified public accountant are attached.
  3. Any refund due the Department shall be submitted with the audit report. The refund shall be on a separate check from any interest due to the Commonwealth and the check shall be made payable to the “Commonwealth of Pennsylvania.”
  4. Any interest earned on funds acquired shall be returned immediately to this office for processing. The interest shall be on a separate check from any refund due to the Commonwealth and the check shall be made payable to the “Commonwealth of Pennsylvania.”

Signature of Local Project Coordinator: / Title: / Date:

DCNR USE ONLY

Close-Out Authorized by: Date: ______
(Initials)
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