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Coronavirus Local Fiscal Recovery Fund - Request For Payment
1. General Information
Participant Name:
Tax ID Number (9-digits):
DUNS Number:
Federal Congressional District (1-9):
NEU Recipient Number
Registered on
Yes No
Mailing Address:
ZIP Code:
Contact Phone
Contact Email
Authorized Representative
Name and Title
(Chief Executive of Participant):
Representative Email:
Please provide the following bank information if you want funds directed to an account other than what is currently
used for transfers to your community from the State Auditor
Bank Name:
Bank Routing Number:
Account Name:
Account Number:
2. Verification of Allocation
a. Top Line 2020 Budget:
b. 75% of Top Line 2020 Budget:
c. US Treasury Allocation:
The US Treasury Allocation cannot exceed 75% of the Top Line 2020 Budget. Your Top Line Budget on the IFA Web Site
was provided by the State’s Department of Local Government Finance (DLGF) based upon your Form 4 - Budget
Ordinance submitted to the DLGF. If line b above exceeds line c, attach your Form 4-Budget Ordinance that was
submitted to the DLGF as Exhibit A to this Request Form. If line b above does not exceed Line c, then please use your
calculations to complete lines a and b and provide documentation of that calculation as Exhibit A to this Request for
3. Certification/ Signature
a. I have read and signed the attached Exhibit B hereto - the US Treasury Coronavirus Local
Fiscal Recovery Fund Award Terms and Conditions.
Yes No
b. I have read and signed the attached Exhibit C hereto - the US Treasury Coronavirus Local
Fiscal Recovery Fund Assurances of Compliance with Civil Rights Requirements.
Yes No
c. Our Community has determined to DECLINE our US Treasury funding allocation, thereby
cancelling the award in order for our community not to be responsible for their appropriate
use and / or repayment.
Yes No
The undersigned hereby certifies under penalties of perjury that the above answers are true and accurate and I have been
duly authorized to execute this Request for Payment.
Attested By (Chief Financial Officer-e.g. Clerk Treasurer)
For Internal Use Only:
Approved By:
Please return this Request and all supporting documentation to the Indiana Finance Authority
Via E-mail:; or
Via Regular Mail: Indiana Finance Authority, One North Capitol, STE 900 Indianapolis, IN
This information can be obtained from the IFA Website
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Exhibit A Support for the calculation of the NEU’s Top Line Budget Amount
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Exhibit B US Treasury Terms and Conditions
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Exhibit C US Treasury Title VI of the Civil Rights Act of 1964