U.S. EPA PAYMENT REQUEST

Recipient Name: Contact Person:

Phone #:

Fax #: Email address:

EFT #

Request #	Cash on Hand: $

Assistance Agreement

Account No/Activity Code

(Superfund Site Specific)

$ Amount	Mark (X) if Credit

For EPA Internal Use Only
TOTAL AMOUNT REQUESTED $
I certify that to the best of my knowledge and belief the data above are correct

and that all outlays were made in accordance with the grant conditions or other

agreement and that payment is due and has not been previously requested.

APPROVALS:

Recipient Approving Official's Signature	Date Approved

$

EPA Certifying Officer Approval	Date Approved	EPA APPROVED AMOUNT

For EPA Use Only

EPA 190-F-04-001