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[null,"Request for Funds"]
[]
[null,"Subgrantee Name:",null,null,null,null,null,null,null,null,null,null,"Date of Request:"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"        Period Covered by this Request"]
[null,"Grant Title:",null,null,null,null,"Specialty Docket Grant"]
[null,"        Finance Officer Address 1:",null,null,null,null,null,null,null,null,null,null," From:",null,null,null,"To:"]
[null,"        Finance Officer Address 2:",null,null,null,null,null,null,null,null,null,null,"To:"]
[null,"        Finance Officer Address 3:",null,null,null,null,null,null,null,null,null,null,"       Federal Identification Number:"]
[null,null,null,"City, State, ZIP:"]
[]
[null,null,"     Drawdown Amount:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"State Grant Funds"]
[null,null,null,"Total Subrecipient Award   (A) ",null,null,null,null,null,null,null,null,null,0]
[null,null,null,"Less: Payments Previously Requested   (B) ",null,null,null,null,null,null,null,null,null,0]
[null,null,null,"(A-B)           Available Amount of Award   (C) ",null,null,null,null,null,null,null,null,null,{"$f":"N21-N22","v":0}]
[null,null,null,"Less: Amount Now Requested  (D)",null,null,null,null,null,null,null,null,null,0]
[null,null,null,"(C-D)        Remaining Grant Balance  (E)",null,null,null,null,null,null,null,null,null,{"$f":"N23-N24","v":0}]
[]
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[null,null,null,null,null,null,null,null,null,"CERTIFICATION"]
[]
[]
[null," I Certify that, to the best of my knowledge, the information above is correct and that all expenditures will be made in accordance "]
[null,"with grant conditions and that payment is due and has not been previously requested."]
[]
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[null,null,"   Signature of Authorized Official",null,null,null,null,null,null,null,null,"Print Name and Title"]
[]
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[null,null,null,null,null,null,null,null,null,"(DO NOT WRITE BELOW THIS LINE -- FOR OES USE ONLY)"]
[null,"Approved for Disbursement",null,null,null,"|"," ","|",null,null,"|",null,null,"|","|"]
[null,null,null,null,null,null,"(FF)",null,null,"(SF)",null,null,null,null,null,"(Total)"]
[null,null,null,null,"Fiscal Reviewer:  ",null,null,null,null,null,null,"Voucher Number: "]
[null,null,null,null,"Date:  ",null,null,null,null,null,null,"Voucher Date: "]

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