EcoAction successful recipients: payment request form

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Section 1: Recipient and Project Identification
EC Finance ID#:    Claim #:    Final Payment:


Recipient Name:


Project Title:


Address:


Contact Name: Contact Phone Number :


Email Address:


Fiscal Year: Claim Period : to


Payment Method: Recipient's Reference/Invoice #(If applicable):



Section 2: Accounting for Eligible Expenditures Paid this Fiscal Year
Expenditure type Current Accounting Previous Balance Total for this Fiscal Year
 
 
 
 
 
 
 
 
 
 
 
 
TOTAL Eligible Project Costs   (a)    


Section 3 : Advances
                                                                                                                                      Amount 
Advance limit for current fiscal year(from section 7 b)iii of your agreement    (b)
Advance(s) already issued    (c)
Advance(s) previously accounted for (excluding amount from section 2 above)    (d)
Advance(s) to be accounted for in Section 2 above    (e)=lesser of (a) and (c)-(d)
Advance that is unaccounted for    (f)=(c)-(d)-(e)
Current available advance limit    (g)=lesser of (b)-(f) and (h)-(i)
Advance requested(see note below)    must be less than or equal to (g)

Note: You must clearly demonstrate the need for any advance. Provide an updated cashflow, if it has changed since the last time submitted to EC.
You should also provide other supporting documents to demonstrate the need for any advance, clearly indicating a gap between the timing of the project costs and the funding received from all project funders.


Section 4 : Payment Amount
This Payment Requested 
Reimbursement of Eligible Expenditures Requested    
 Adance Payment Requested   
Payment to be Issued   


Section 5 : Advances
  Current Fiscal Year
Total EC Funding   (h)
Total of previous advance payments and reimbursements   (i)
Current payment (from section 4 above)   
Total Payments   
Balance of EC Funding Available   


Section 6 : Recipient Certification

I hereby certify that the information provided in this form is accurate and that(1) any reimbursement requested or accounting for advance is for an eligible expenditure as defined by the Agreement and/or (2) any advance requested will be used in accordance with the Agreement.


Name and Title (Print): Signature: Date:


DEPARTMENTAL USE ONLY

Verified by:                                                                              Certified pursuant to s.34 of the FAA

Name:
Date:
Name (print):
Signature:
Date:


Line of Coding Amount
Invoice Number: Financial:    
Commitment: Coding:    

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