MEA Resilient Maryland Program, AOI 2 Reimbursement Request

1
MEA Grant Number* This field is required.Enter the Grantee's MEA Grant Number. This can be found in the upper right corner on the first page of the Grant Agreement.
2
Grantee Name* This field is required.Enter the name of the Grantee organization, as it appears on its IRS Form W9.
3
Grantee Address (as listed on Grantee's IRS Form W9)* This field is required.Enter the address information for the Grantee below. Be sure that the address that you enter exactly matches how it appears on the Grantee's IRS Form W9.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
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Guinea
Guinea-Bissau
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Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
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Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
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Tonga
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Vanuatu
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Current Grantee Point of Contact* This field is required.Enter the contact information for the Grantee's current point of contact. MEA will reach out to this individual with any questions about this report or communications about the project.
ENTER FULL NAME (FIRST AND LAST)
Title
Email Address
Phone Number
5
REMINDER: ELIGIBILITY FOR REIMBURSEMENT OF GRANT FUNDS

Reimbursement Requests shall only be submitted by Grantee upon acheiving each respective Project Milestone (as defined by the Grant Agreement with MEA) below.

Final Engineering Completion (up to 15% of grant funds);

Project Groundbreaking (up to 70% of grant funds, inclusive of the Final Engineering Completion Reimbursement, if taken);

Project Completion (up to 90% of grant funds, inclusive of all prior reimbursement(s) taken); and

Performance Verification (remaining balance of grant funds).

Only costs that are consistent with the following requirements are eligible for reimbursement of Grant funds:

Costs directly incurred by Grantee (i.e., invoiced);

Costs directly attributable to the completion of the specified Project, set forth in Attachment B;

Costs for projected future expenses yet to be incurred will not be reimbursed; and

MEA will only reimburse Grantee for eligible expenses up to the amount specified in the Grant Agreement.

How to Calculate Reimbursement Amounts

The table below provides instructions on how to calculate the reimbursement request amount, based on the Project Milestone it is for.

Project Milestone	Calculation
Final Engineering Completion	Total Grant Amount x 0.15
Project Groundbreaking	(Total Grant Amount x 0.70) - Final Engineering Completion Reimbursement
Project Completion	(Total Grant Amount x 0.90) - (Final Engineering Completion Reimbursement + Project Groundbreaking Reimbursement)
Performance Verification	Remaining Balance of Grant Funds

7
Which Project Milestone Reimbursement Request are you submitting for?* This field is required.
Please Select
Please Select
Final Engineering Completion
Project Groundbreaking
Project Completion
Performance Verification
8
Reimbursement Request Amount* This field is required.Enter the dollar amount that you are requesting reimbursement for.
9
Itemized Cost Information* This field is required.List each itemized cost that you're requesting reimbursement for in the table below. If applicable, supply the invoice number in the “Contractor Invoice No.” box. If additional lines are needed, you will need to submit a second reimbursement request for the remaining line items.
Line Item Description
Contractor/Vendor Invoice Number
Amount ($)
01
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
02
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
03
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
04
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
05
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
06
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
07
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
08
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
09
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
10
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
11
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
12
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
13
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
14
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
15
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
Line Item Description
Row 0, Column 0
Contractor/Vendor Invoice Number
Row 0, Column 1
Amount ($)
Row 0, Column 2
Line Item Description
Row 1, Column 0
Contractor/Vendor Invoice Number
Row 1, Column 1
Amount ($)
Row 1, Column 2
Line Item Description
Row 2, Column 0
Contractor/Vendor Invoice Number
Row 2, Column 1
Amount ($)
Row 2, Column 2
Line Item Description
Row 3, Column 0
Contractor/Vendor Invoice Number
Row 3, Column 1
Amount ($)
Row 3, Column 2
Line Item Description
Row 4, Column 0
Contractor/Vendor Invoice Number
Row 4, Column 1
Amount ($)
Row 4, Column 2
Line Item Description
Row 5, Column 0
Contractor/Vendor Invoice Number
Row 5, Column 1
Amount ($)
Row 5, Column 2
Line Item Description
Row 6, Column 0
Contractor/Vendor Invoice Number
Row 6, Column 1
Amount ($)
Row 6, Column 2
Line Item Description
Row 7, Column 0
Contractor/Vendor Invoice Number
Row 7, Column 1
Amount ($)
Row 7, Column 2
Line Item Description
Row 8, Column 0
Contractor/Vendor Invoice Number
Row 8, Column 1
Amount ($)
Row 8, Column 2
Line Item Description
Row 9, Column 0
Contractor/Vendor Invoice Number
Row 9, Column 1
Amount ($)
Row 9, Column 2
Line Item Description
Row 10, Column 0
Contractor/Vendor Invoice Number
Row 10, Column 1
Amount ($)
Row 10, Column 2
Line Item Description
Row 11, Column 0
Contractor/Vendor Invoice Number
Row 11, Column 1
Amount ($)
Row 11, Column 2
Line Item Description
Row 12, Column 0
Contractor/Vendor Invoice Number
Row 12, Column 1
Amount ($)
Row 12, Column 2
Line Item Description
Row 13, Column 0
Contractor/Vendor Invoice Number
Row 13, Column 1
Amount ($)
Row 13, Column 2
Line Item Description
Row 14, Column 0
Contractor/Vendor Invoice Number
Row 14, Column 1
Amount ($)
Row 14, Column 2
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10
Supporting Invoice and Documentation Upload* This field is required.Upload all supporting invoices matching the itemized cost information you entered into the previous table. All costs must be documented.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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11
Name of Authorized Representative (Person Signing this Form)* This field is required.
First Name
Last Name
12
Title of Authorized Representative (Person Signing this Form)* This field is required.
13
Certification and Signature of Authorized Representative* This field is required.By signing this invoice, I affirm that the costs for which I have requested reimbursement are directly attributable to the Project Description pursuant to Attachment B of the Grant Agreement and that all applicable terms, conditions, and requirements of the Grant Agreement have been met. I affirm that I have correctly itemized all costs on the second page of this Reimbursement Request. Click "SUBMIT" when you have signed the form to submit the reimbursement request directly to MEA.
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