Subaward Invoice Payment Request

Subaward Invoice Payment Request Form

Please use this form to submit and request reimbursement for subaward invoices.
Organization/Entity Name:
Please enter the name of your organization or entity.
Subaward Number *
The subaward number is a 6 digit number formatted as ##-####. For example; 23-1855. This can be found on your subaward agreement.
Purchase Order Number *
The purchase order number is a 10 digit number that begins with "20000XXXXX" and can be found on your subaward agreement.
Project Number
The project number is an 8 digit number that begins with "100XXXXX" and can be found on your Subaward Agreement.
Invoice Performance Period or Service Dates:*

Start Date End Date

Invoice Dates
Invoice Number
Invoice Amount*
Please enter the total amount due per the invoice in USD.
Is this a final invoice?*

YesNo
Please upload your invoice and any supporting documentation as applicable.*

Cancelof
CERTIFICATION:

Non-Federal Certification (if applicable): I certify to the best of my knowledge and belief that this invoice is true, complete, and accurate and the expenses herein were for the purposes and objectives set forth in the terms and conditions of the award.

Federal Certification (if applicable): By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729–3730 and 3801–3812).
CERTIFICATION*

YesNot applicable (Installment or Fixed Price Payment Request)
Comments for approvers:
Please provide any additional comments here as needed.
Organization Contact Information - Please enter your name:

First NameLast Name
Organization Contact Email - Please enter your contact email address:
example@example.com
Should be Empty:

Subaward Invoice Payment Request Form