NC Urban and Community Forestry Grant Program
Contract #
Reimbursement for period through
Grantee Name
Federal Tax ID Number (FEIN)
Street or PO Box Number
City / State / Zip
Attention: (Person/Department to receive payment)
Complete the Following if Requesting Final Reimbursement
Date Project Completed
Total Project Cost (include current and previous amounts)
A. Federal Share (Total Reimbursements) $
B. Grantee Share (Total Cash Match) $
C. Grantee Share (Total In-Kind Match) $
D. Total Match (B+C) $
(must equal or exceed Total Reimbursements)
E. Total Project Cost (A+D) $
Reimbursements Requested Today
A. Federal Funds Requested for
Reimbursement (This Period) $
Non-Federal Match (This Period)
B. Cash Match this Period $
C. In-Kind Match this Period $
Total Match this Period (B+C) $
(must equal or exceed reimbursement request amount)
Reimbursement Request minus 20%
holdback (until project completed) $
For NCFS Official Use Only
Payment Approved by:
Amount: $
20% holdback included
in final payment
Grantee Certification: I certify that this request for
reimbursement of funds is in accordance with the terms and
conditions of the North Carolina Urban and Community
Forestry Grant Program and the rules and regulations set forth
by the USDA Forest Service and the United States Office of
Management and Budget. I also certify that matching
requirements have been met and sufficient documentation
exists in our files and are available upon request or in the
event of an audit. I also certify that all data and
accomplishments reported are correct.
Print Name of Authorized Representative
Title of Authorized Representative
Signature of Authorized Representative (sign with BLUE ink)
1. Attach Expense and Match Documentation Form (and
Manpower and Equipment Documentation if needed).
2. Attach copies of documentation for grant expenses:
receipts, paid invoices, payroll records, etc. for grant
expenses and for match items. Number each receipt
item and itemize on the form
3. If requesting final reimbursement, complete Parts I & II
of this form, otherwise only complete Part I.
4. If requesting final reimbursement, include the Final
Accomplishment Report, Accomplishment Narrative, and
other required documentation.
5. Keep a copy of everything submitted.
6. All project records, including financial records, must be
maintained for 5 years beyond project completion.