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Yes No
State of Alaska
Department of Administration
Alaska Public Broadcasting Commission
Capital Grant Report


Department of Administration
Division of Administrative Services
P.O. Box 110208, Juneau, AK 99811-0208
Phone (907) 465-2403 Fax (907) 465-2194

rev. 5/07


Grantee Name and Address

Grant Number:



Grant Name



Report Number


Final Report
Yes No


P
AYMENT
R
EQUEST


Report Period (Month, Day, Year)


A) Total Previously reported
expenditures (from line C of
previous report



From

To

B) Expenditures this period

Remarks


C) Total expenditures to date




D) Total Grant Amount




E) State Payments to Date
(including advance)




F) Grant Amount Available




G) State Payment Requested




DATE

Amount

Expenditure Detail (list Vendors)































Total



If additional space is required, please report expenditures on a separate page and attach.

I certify that to the best of my knowledge and belief, the data reported herein is correct and all outlays were made in accordance with grant
conditions and the payment is due and has not been previously requested.


Signature of authorized official



Printed Name



Title



Date



Telephone



Fax



For State use only


PVN



AR


Batch


Encumbrance


Approved for payment
(initials of State Administrator)



INSTRUCTIONS FOR COMPLETING THIS FORM


1.
Grantee Name and Address: Enter the name and address of the grantee.

2.
Grant Number and Grant Name: Enter the grant number and grant name used by the Department of
Administration

3. Report
Number: Enter the report number. The first report would be number 1, the second would be
number 2, etc.

4. Final
Report: Mark the appropriate box.

5. Report
Period: Enter the month, day and year of the beginning and ending dates for which this
report is prepared.

6. Payment
Request

Line A
Enter expenditures that were reported on previous reports. This Line will be Line C
from the previous financial report.

Line B
Expenditures are the sum of actual cash disbursements for goods and services and
amounts owed or accrued for payment if the payment is due within 30 days. This would
include monthly payroll. If an obligation is made but is not due for in excess of thirty
days it cannot be claimed as an expenditure until such time as the due date is within
thirty days of the date the report is submitted.

Line C
This amount will be the sum of Line A and Line B

Line D
This is the total grant amount.

Line E
This is the total amount of state payments received. This amount includes the advance
payment.

Line F
This is the difference between Line D and Line E

Line G
This is the difference of Line C and Line E, once the total expenditures exceed the state
payments to date.

7. Remarks: This space is provided for any motes, comments or explanations the grantee wishes to
make.

8. Expenditure
Detail: List all expenditures made during the report period. The total of the listed
expenditures must equal the amount that appears on Line B of the payment request.