17-CA/I-001
Automotive Industry Apprenticeship Trust Fund

Request for Advance or Reimbursement NOTE: No further monies or other benefits may be paid out unless this report is completed and filed as required by existing law and regulations (34 CFR 256)
  1. Type of payment requested
 a. X Advance 2. Basis of Request
Reimbursement
b. Final X Cash
X Partial Accrual
3. Federal Sponsoring Agency and Organizational Element to Which Report is Submitted:

Federal Mediation and Conciliation Service, Grants
 4. Federal Grant or Other Identifying No. Assigned by Federal Agency:

 5. Partial Payment Request Number for This Request:

1.0
6. Employer Identification No.

 7. Period Covered by This Request
From: 10/01/2017 To: 11/01/2017
8. Recipient Organization
Name:
Street:

City, State Zip:


,
9. Computation of Amount of Reimbursement / Advances Requested
a: Total Program Outlays as of 11/02/2017 $0.00
b: Cumulative Program Income $0.00
c: Net Program Outlays (a minus b) $0.00
d: Estimated Net Cash Outlays for Advance Period $5,725.00
e: Total (c plus d) $5,725.00
f: Non-Federal Share of e (Grantee Match) $572.50
g: Federal Share of e $5,152.50
h: Federal Payments Previously Requested $0.00
i: Federal Share Now Requested (g minus h) $5,152.50
10. Certification
I certify that to the best of my knowledge and belief the data above are correct and that all outlays were made in accordance with the grant conditions or other agreement and that payment is due and has not been previously requested. Signature of Authorized Certifying Official

Kim Settle
 Date Request Submitted:

01/24/2018
Title: Program Services Administrator
Phone: 916-567-9911
Clearance Approved For Payment Approved Grant Manager’s Signature

Linda G. Broughton
 Date:

01/24/2018
Approved Financial Management Office

Amanda S. Cobb
 Date:

01/24/2018
Schedule Number

MA180400002551
 Date Processed

01/25/2018
 Signature

01/25/18
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