Once processed, please remember to obscure the recipient’s Social Security Number Revised July 2011
MASSACHUSETTS CULTURAL COUNCIL
LOCAL CULTURAL COUNCIL PROGRAM REIMBURSEMENT FORM
Grantee___________________________________________________________
Project Title________________________________________________________
Total award amount $___________ Amount to be paid now $__________
*Please attach supporting documentation such as copies of programs, fliers, press, invoices, cancelled checks,
receipts, etc. as required by the local cultural council for payment.
This request is: 1. a progress payment 2. for the grantee
or or
a final payment for third-party vendor
MAKE CHECK PAYABLE TO:
NAME____________________________________________________________________
ADDRESS__________________________________________________________________
CITY/TOWN_________________________________STATE/ZIP______________________
TAX ID #/FED EMPLOYEE # OR SOCIAL SECURITY #_________________________________
"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 MCC’s website at www.massculturalcouncil.org."
[If your grant was approved with a CONDITION]: "I further testify that the condition imposed on the project has been
met."
Signed under the pains and penalties of perjury:
____________________________________________________________ _______________
Signature of grantee or officer of grantee organization with Date
legal authority to bind and execute this certification
FOR LOCAL CULTURAL COUNCIL USE ONLY: Must be completed and signed by at least two cultural council members
Please check:
ÿ The LCC has notified the grantee of the credit policy outlined in the LCC Program Regulations and Guidelines.
ÿ The grantee has completed all or part of the project described in the approved application, and has submitted
appropriate supporting documentation regarding how funds were used.
____________________________________ ___________________________________ _______________
LCC Member Signature Print Name Date
____________________________________ ___________________________________ _______________
LCC Member Signature Print Name Date
Application Number __________
click to sign
signature
click to edit
![]()
