Community Support Agency Grant Program
THIRD QUARTER PAYMENT REQUEST
Agency Name: ________________________________________________________________________
Address: ____________________________________________________________________________
______________________________________________________________________________
Phone: ___________________ Fax: ___________________
Contact Person: __________________________________
Phone: _________________ Email: ___________________
Total Amount of Grant: $__________________
Funds Previously Distributed: $__________________
Balance Remaining to Date: $__________________
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 January 15, along with the Mid Year Performance Measures Reporting Form, the
Mid Year Financial Reporting Form, and an independent audit of your agency’s last completed fiscal
year. 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
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