NAME____________________________________________________________
[If your grant was approved with a CONDITION]: "I further testify that the condition imposed on the project has been
met.”
FOR LOCAL CULTURAL COUNCIL USE ONLY: Must be completed and signed by at least two Cultural Council
members.
Once processed, please obscure the recipient’s Social Security or Tax ID number. Revised July 2018
TAX ID/ FED EMPLOYEE ID/SOCIAL SECURITY # _________________________________
[ ] final payment [ ] third-party vendor
For Council Use: Application #
_____________________
Grantee________________________________________________________
Contact Phone ___________________________________________________
Contact Email ___________________________________________________
LOCAL CULTURAL COUNCIL PROGRAM
REIMBURSEMENT FORM
Total award amount $____________ Amount to be paid now $_____________
Project Title ____________________________________________________
__ The grantee has completed all or part of the project described in the original proposal approved, and has submitted
appropriate supporting documentation regarding how funds were used.
ADDRESS_________________________________________________________
CITY/TOWN_____________________________STATE/ZIP________________
LCC Member Signature Print Name Date
__________________________________ ________________________________ _______________
LCC Member Signature Print Name Date
__________________________________ ________________________________ _______________
________________________________________________________________________________________________
__ The LCC has notified the grantee of the credit policy outlined in the LCC Program Regulations and Guidelines.
Signature of grantee or officer of grantee organization with Date
legal authority to bind and execute this certification
____________________________________________________ _______________
Signed under the pains and penalties of perjury:
"As grantee for the project as detailed above, I certify that the statements made herein are true and that the funds
requested to be disbursed fulfill the purpose indicated in the approved application, and that I have fulfilled the credit
policy requirements outlined on the Mass Cultural Council website."
This request is: 1. [ ] a progress payment 2. [ ] for the applicant
Please attach supporting documentation such as copies of programs, press, invoices, cancelled checks, and receipts, as
required by the Local Cultural Council for payment.
click to sign
signature
click to edit
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