Read more about the Community Development Block Grant CV Program invoice instructions Step 1 of 4 - GENERAL INFORMATION 0% SECTION I: GENERAL INFORMATION1. GRANTEE NAME* 2. DCED CONTRACT NUMBER:* 3. PROGRAM YEAR:* 4. CONTRACT AMOUNT:*5. CONTRACT ACTIVITY PERIOD (MONTH, DAY, YEAR):FROM* MM slash DD slash YYYY TO:* MM slash DD slash YYYY 6. INVOICE REPORTING PERIOD (MONTH, DAY, YEAR):FROM:* MM slash DD slash YYYY TO:* MM slash DD slash YYYY SECTION II: FISCAL INFORMATIONDo you have any other income on hand?* Yes No If yes, how much?Please select the type Program IncomeCash On HandRevolving Loan FundsRepayment to Local Account Are any activities reported on this invoice multi-year projects?* Yes No DCED USE ONLY Conditions Fiscal Information Calculation1. IDIS ACTIVITY NAME (INCLUDING ADMIN)2. IDIS ACTIVITY NUMBER3. IS THIS A MULTI-YEAR PROJECT?4. EXPENDITURES THIS INVOICE PERIOD (DO NOT DEDUCT OTHER INCOME)5. OTHER INCOME TYPE6. GRANTEE USE ONLY (OTHER INCOME USED)ER DATENOT METMETN/A NoYesProgram IncomeCash On HandRevolving Loan FundsRepayment to Local AccountYesNoYesNoYesNo NoYesProgram IncomeCash On HandRevolving Loan FundsRepayment to Local AccountYesNoYesNoYesNo NoYesProgram IncomeCash On HandRevolving Loan FundsRepayment to Local AccountYesNoYesNoYesNo SECTION III: INVOICE INFORMATION1. Other Income On Hand2. Expenditures this Invoice Period3. Other Income Used4. Cash on Hand Used (Manual Input)5. Total Amount Requested (2-4=5)COMMENTS*If you have any other income or multi-year activities, describe them here.COMMENTSIf you have any other income or multi-year activities, describe them here. SECTION IV: CERTIFICATIONPursuant to the Pennsylvania Electronic Transactions Act – Act 69, effective January 15, 2002, you are about to engage in an electronic transaction with the Commonwealth of Pennsylvania. You are submitting official information. You certify under penalty of law that this document and all attachments were prepared under your direction or supervision in accordance with a system designed to assure that qualified personnel gather and evaluate the information submitted. Based on your inquiry of the person or persons who manage the system or those persons directly responsible for gathering the information, the information submitted is, to the best of your knowledge and belief, true accurate and complete. You are aware that any false statement may be subject to substantial civil and criminal penalties, including 18 P.S. section 4904 (relating to unsworn falsification to authorities). NOTE: The AUTHORIZED SIGNATOR must be an elected official or designated individual other than the contact person listed.I certify that all information submitted for processing of this payment request is accurate and eligible under the program. Other income earned has been expended prior to drawing funds from IDIS.* I certify that I have reviewed and approve this invoice submission. I certify that I am the authorized signatory for the contract listed above. 1. GRANTEE'S AUTHORIZED SIGNATURE:*2. NAME:* 3. TITLE:* 4. AUTHORIZED SIGNATURE EMAIL ADDRESS:* 5. TODAY'S DATE:* MM slash DD slash YYYY Any false statements made willfully may be subject to penalties under Section 1001 of Title 18 of the United States Code. The initial review performed by DCED on this invoice does not constitute acceptance of its associated expenditures. DCED's Compliance Monitoring Division will conduct a comprehensive review during the contract period to ensure eligibility of all related expenditures.6. CONTACT PERSON:* 7. TITLE:* 8. PHONE NUMBER:*9. EMAIL ADDRESS:* DCED USE ONLYHiddenREVIEWER NAME: HiddenDATE EMAIL SENT: MM slash DD slash YYYY HiddenQA Email NameThis field is for validation purposes and should be left unchanged.