Fillable CLFRF Request For Payment (State of Indiana)

Fill Online, Printable, Fillable, Blank CLFRF Request For Payment (State of Indiana) Form

Use Fill to complete blank online STATE OF INDIANA (IN) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CLFRF Request For Payment (State of Indiana)

On average this form takes 9 minutes to complete

The CLFRF Request For Payment (State of Indiana) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Indiana

BROWSE STATE OF INDIANA (IN) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Final on <date>
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
1
:
Registered on SAM.gov:
☐ Yes ☐ No
Mailing Address:
City:
State:
IN
ZIP Code:
Contact
Person:
Contact Phone
Number:
Contact Email
Address:
Authorized Representative
Name and Title
(Chief Executive of Participant):
Authorized
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
1
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
Payment.
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.
By:
Printed:
Title:
Date:
Attested By (Chief Financial Officer-e.g. Clerk Treasurer)
By:
Printed:
Title:
Date:
For Internal Use Only:
Approved By:
Date:
$
$
Please return this Request and all supporting documentation to the Indiana Finance Authority
Via E-mail: COVID-19@ifa.in.gov; or
Via Regular Mail: Indiana Finance Authority, One North Capitol, STE 900 Indianapolis, IN
1
This information can be obtained from the IFA Website
Final on <date>
Exhibit A – Support for the calculation of the NEU’s Top Line Budget Amount
Final on <date>
Exhibit B – US Treasury Terms and Conditions
Final on <date>
Exhibit C – US Treasury Title VI of the Civil Rights Act of 1964
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CLFRF Request For Payment (State of Indiana)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document