Community Support Agency Grant Program
FIRST QUARTER PAYMENT REQUEST
Agency Name: ________________________________________________________________________
Address: ____________________________________________________________________________
______________________________________________________________________________
Phone: ___________________ Fax: ___________________
Contact Person: __________________________________
Phone: _________________ Email: ___________________
Total Amount of Grant: $__________________
Funds Requested (25% of total grant): $__________________
Balance Remaining After This Request: $__________________
An advance of 25% of the grant allocation is hereby requested to cover anticipated expenditures of the
agency.
Typed Name of Authorized Official: _____________________________
Signature of Authorized Official: _____________________________
Date: _____________________________
Submit this form by July 30, along with a signed Conditions of Grant Award form, the Adopted Budget
form, and the Proposed Performance Measures form.
Submit in hardcopy or electronic format to:
City of Newport News
Department of Budget & Evaluation
2400 Washington Avenue, 9th Floor
Newport News, VA 23607
(757) 926-8733
budget@nnva.gov
Note: A payment request is not required for your second quarter payment.
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