Community Development Block Grant CV Program Invoice – DCED-FMC-CDBG-CV-013

Read more about the Community Development Block Grant CV Program invoice instructions

Step 1 of 4 - GENERAL INFORMATION

SECTION I: GENERAL INFORMATION
1. GRANTEE NAME*
2. DCED CONTRACT NUMBER:*
3. PROGRAM YEAR:*
4. CONTRACT AMOUNT:*
5. CONTRACT ACTIVITY PERIOD (MONTH, DAY, YEAR):
FROM*
Date Format: MM slash DD slash YYYY
TO:*
Date Format: MM slash DD slash YYYY
6. INVOICE REPORTING PERIOD (MONTH, DAY, YEAR):
FROM:*
Date Format: MM slash DD slash YYYY
TO:*
Date Format: MM slash DD slash YYYY

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SECTION II: FISCAL INFORMATION
Do you have any other income on hand?*
- Yes
- No
If yes, how much? Please select the type
Are any activities reported on this invoice multi-year projects?*
- Yes
- No
DCED USE ONLY
Conditions

Fiscal Information Calculation

1. IDIS ACTIVITY NAME (INCLUDING ADMIN)	2. IDIS ACTIVITY NUMBER	3. IS THIS A MULTI-YEAR PROJECT?	4. EXPENDITURES THIS INVOICE PERIOD (DO NOT DEDUCT OTHER INCOME)	5. OTHER INCOME TYPE	6. GRANTEE USE ONLY (OTHER INCOME USED)	ER DATE	NOT MET	MET	N/A

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SECTION III: INVOICE INFORMATION
1. Other Income On Hand
2. Expenditures this Invoice Period
3. Other Income Used
4. 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.
COMMENTS
If you have any other income or multi-year activities, describe them here.

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SECTION IV: CERTIFICATION
Pursuant 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:*
Date Format: 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 ONLY
REVIEWER NAME:
DATE EMAIL SENT:
Date Format: MM slash DD slash YYYY
QA Email
Phone
This field is for validation purposes and should be left unchanged.

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If yes, how much?	Please select the type

Step 1 of 4 - GENERAL INFORMATION

SECTION I: GENERAL INFORMATION

SECTION II: FISCAL INFORMATION

SECTION III: INVOICE INFORMATION

SECTION IV: CERTIFICATION

DCED USE ONLY