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Attachment E
JUSTIFICATION OF ADVANCE PAYMENT
RECIPIENT:
Indicate by checking one of the boxes below, if you are requesting an advance. If an advance payment is
requested, budget data on which the request Is based must be submitted. Any advance payment under this
Agreement is subject to s. 216.181 (16)(a)(b), Florida Statutes. The amount which may be advanced shall not
exceed the expected cash needs of the recipient within the initial three months.
[ ) NO ADVANCE,REQUESTED
No advance payment is requested.
Payment will be solely on a
reimbursement basis. No additional
information is required.
ADVANCE REQUEST WORKSHEET
[ 1 ADVANCE REQUESTED
Advance payment of $ is requested. Balance of
payments will be made on a reimbursement basis. These funds
are needed to pay staff, award benefits to clients, duplicate forms
and purchase start-up supplies and equipment. We would not be
able to operate the program without this advance.
If you are requesting an advance, complete the following worksheet.
.
DESCRIPTION
(A)
FFY 2004
(B)
FFY 2005
(C)
FFY 2006
(0)
Total
1
INITIAL CONTRACT ALLOCATION
2
FIRST THREE MONTHS CONTRACT
EXPENDITURES1
_
3
AVERAGE PERCENT EXPENDED IN FIRST
THREE MONTHS
(Divide line 2 by line 1.)
First three months expenditures need only be provided for the years in which you requested an advance.
If you do not have this Information, call your consultant and they will assist you.
MAXIMUM ADVANCE ALLOWED CALULATION:
X $
HMGP Award MAXIMUM
(Do not Include match) ADVANCE
CeII D3
REQUEST FOR WAIVER OF CALCULATED MAXIMUM
[ 1 Recipient has no previous HMGP contract history. Complete Estimated Expenses chart
and. Explanation of Circumstances below.
[ 1 Recipient has exceptional circumstances that require an advance greater than the Maximum
Advance calculated above. Complete estimated expenses chart and Explanation of Circumstances
below. Attach additional pages if needed.
31
•
ESTIMATED EXPENSES
BUDGET CATEGORY
2006-2007 Anticipated Expenditures for First Three Months of
Contract
ADMINISTRATIVE COSTS
PROGRAM EXPENSES
TOTAL EXPENSES
Explanation of Circumstances:
32