Fund Request Summary
1.  Local Partnership Name:	6.  Contract #:
2.  Organization Name:	Purpose/Service Code:
3.  Mailing Address:	7.  Contract Period:
	8.  Contact Person:
	9.  Telephone #:
4.  Program/Activity:	10. Period covered by this request:  (  ) Initial Draw
5.  Final Report  |          |               Amended Report  |         |	From:	To:
Computation of Cash Requirements
11. Current Period Expenditures (From FSR)			$
12. Additional Amount Requested (attach explanation)			$
13. TOTAL CASH PAYMENT REQUESTED			$
CERTIFICATION:  I CERTIFY THAT THE ABOVE DATA ARE CORRECT AND THE EXPENDITURES SHOWN HAVE BEEN
MADE FOR THE PURPOSE OF AND IN ACCORDANCE WITH APPLICABLE CONTRACT TERMS AND CONDITIONS AND THAT
APPROPRIATE DOCUMENTATION TO SUPPORT THESE COSTS AND EXPENDITURES ARE AVAILABLE.
Contractor Signature :__________________________________________	Title:_________________________  Date:  __________
Local Partnership Signature: _____________________________________	Title:_________________________  Date:  __________
For CCPFC Use Only
Account Code:                                                              Prepared by:
Date:
Total Cash Received & Requested thru Last FSR	$
Cash Payment Requested Above	$
YTD Total Cash Received & Requested	$
YTD Expenditures	{$                         }
Cash on Hand	$
Initial Draw	$
COMMENTS:
Approved          $___________________________	Check #: _______________
Controller :____________________________________	Paid:__________________
Date Approved   ________________________________
Business Office Director:  ________________________
Date Approved   ________________________________