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City of Cleveland Community Development Block Grant
Request for Payment and Status of Funds Report
Request/Report No. Name and Address of Agency Date: Name and Address of Depository
Contract No.: Matrix Code: Project Activity No.: 1. 2. 3. 4. 5. 6. 7. Total Amount Recieved from CDBG Less: Total Costs Incurred to Date (Page 2, Column 3 Total) Funds on Hand (Line 1 - 2) Amount Incurred this Month (Page 2, Column 2 Total) Amount Requested Amount Requested and Not Received Total (Line 3 + 4 + 6 )
Account Number: Amount Requested: 1. 2. 3. 4. 5. 6. 7. $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Certification to be Completed by Drawer: I certify that this request for payment has been drawn in accordance with the terms and conditions of Contract Number 0 between 0 and the City of Cleveland, Department of Community Development and that the amount for which drawn is proper for credit to the account of the drawer at the drawer's designated depository. I also certify that the data reported above is correct and the amount of the request for payment is not in excess of current needs.
Date
Authorized Signature FOR CITY OF CLEVELAND USE ONLY PeopleSoft Received: Approved: Financial Analyst Approved: Contract Administration Manager
MPR Check-Off CCR #
Title
Logged Date Date Date
IDIS Data Prevailing Wage/ Affirmative Market Section 3/HOME
Date Date Date
Acq./Relocation Historic Pres./ Environmental Compliance Manager
Date Date Date
Revised 2/17/04
City of Cleveland Community Development Block Grant
Monthly Budget Report
Month Of Actual Dates of Reporting Period Operating Agency Program Contract Time of Performance: (1) Latest Approved Budget (2) Cost Incurred This Month $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Contract Number to (3) Total to Date (last month. Col. 3 + Col. 2) (4) 0 to
Cost Categories 1. Personnel 2. Fringe Benefits 3. Travel 4. Equipment 5. General Overhead 6. Contractual 7. Other A. B. C. D. E. F. G. H. I. J. K. Total
Free Balance $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
$0.00
$0.00
$0.00
Date
Authorized Signature
Title
GPR Line Items Matrix Code This Month's Total Total to Date
R:Ponr 14E
Ed Tech Asst 18B
Public Service 05__
Code Interm Enforcement Asst 15 6
Rehab SF 14H
Plan 20
Rehab MF 14A
Constr. of Housing 12
Total
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 $0.00
City of Cleveland Community Development Block Grant
Monthly Budget Report
Month Of Actual Dates of Reporting Period Operating Agency Program 1. Personnel: Total Hours Charged to CDBG This Period 0 0 0 Contract Number 0 to 0 0
Name
Title
Rate of Pay $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Total Hours Worked This Period
CDBG Amount This Period $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL Personnel Costs Incurred This Month: **Time Sheets must Accompany Payment Requests**
$0.00 $0.00 $0.00 $0.00 $0.00
R:Ponr Ed. Tech Interm Asst. Rehab SF Planning
$0.00 $0.00 $0.00 $0.00
Public Service Code Enforcement Rehab MF Constr. of Housing
2. Fringe Benefits: Type of Benefit Rate $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Time Covered Amount $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL Fringe Benefits Incurred This Month: **Most Current Information Rate Must be on File at CA**
$0.00 $0.00 $0.00 $0.00 $0.00
R:Ponr Ed. Tech Interm Asst. Rehab SF Planning
$0.00 $0.00 $0.00 $0.00
Public Service Code Enforcement Rehab MF Constr. of Housing
3. Travel/Mileage: Name # of Miles Rate $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Amount $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Travel Other Than Mileage: Name Purpose Amount $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL Travel costs Incurred This Month:
**Mileage (odometer) log must accompany request for payment**
$0.00 $0.00 $0.00 $0.00 $0.00
R:Ponr Ed. Tech Interm Asst. Rehab SF Planning
$0.00 $0.00 $0.00 $0.00
Public Service Code Enforcement Rehab MF Constr. of Housing
4. Equipment Description Vendor Amount $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL Equipment Incurred This Month: **Documentaiton/Serial Number Must Accompany Request**
$0.00 $0.00 $0.00 $0.00 $0.00
R:Ponr Ed. Tech Interm Asst. Rehab SF Planning
$0.00 $0.00 $0.00 $0.00
Public Service Code Enforcement Rehab MF Constr. of Housing
5. General Overhead: Purpose Vendor Period Covered Amount $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL General Overhead Costs Incurred This Month: **Documentation Must Accompany this Request**
$0.00 $0.00 $0.00 $0.00 $0.00
R:Ponr Ed. Tech Interm Asst. Rehab SF Planning
$0.00 $0.00 $0.00 $0.00
Public Service Code Enforcement Rehab MF Constr. of Housing
6. Contractual Description of Services
Contractor
Period
Amount $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL Contractual Incurred This Month:
**A Signed Contractual Agreement Must be on File with CA. Proper Documentation must be Submitted with Monthly Request for Payment**
$0.00 $0.00 $0.00 $0.00 $0.00
R:Ponr Ed. Tech Interm Asst. Rehab SF Planning
$0.00 $0.00 $0.00 $0.00
Public Service Code Enforcement Rehab MF Constr. of Housing
7. Other: Description Purpose Amount $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL Other Costs Incurred This Month:
**Proper Documentation Must be Submitted with Monthly Request for Payment** $0.00 $0.00 $0.00 $0.00 $0.00 R:Ponr Ed. Tech Interm Asst. Rehab SF Planning $0.00 $0.00 $0.00 $0.00 Public Service Code Enforcement Rehab MF Constr. of Housing
Total Costs Incurred for the Month Of
0
Year $0.00