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1. Enter project number, administering agency, month cash will be needed and report due date.
2. Enter the total amount of Federal funds received since the project began through the most recent prior month.
3. Enter the month(s) that each column (#2, 3, 4 and 5) represents in the spaces enclosed in the parentheses. Enter all figures by category of expenditure. Do Not Include Outstanding Purchase Orders.
   • Column 1:    Enter the Federal budget from the contract according to category of expenditure or the most recent approved budget at the time of this request.
   • Column 2:    Enter the total cumulative funds disbursements from the beginning of the project through the end of the most recent prior month. This should equal the total sum of Cash Disbursements (Column 2) of your previous month "Request For LSTA Funds" plus Actual Cash Disbursements in Column 3 on this Cash Request. This should be the same amount as the total Federal Fund Disbursements you show on your books.
   • Column 3:    Enter actual cash disbursements for the month immediately preceding the current month.
   • Column 4:   Enter estimated disbursements for the current month.
   • Column 5:    Enter estimated disbursements for the month immediately following the current month.
   • Column 6:    This is the estimated uncommitted Federal Fund Balance you have still available for this grant.
     • This is: Column 1:     (Budget)
     • Less:
       • Column 2:    (Total Federal Cumulative Funds Disbursements)
       • Column 4:   (Estimated Funds Disbursements Current Month)
       • Column 5:     (Estimated Funds Disbursements Next Month)
4. Explain any large or unusual estimated disbursements in III.
5. Sign and date request. The form must be submitted by the project's fiscal officer.
6. Submit completed request so it will be received at the State Library of Ohio No Later Than The 10th of the Current Month. Any request received after the 10th of the current month cannot be processed for payment for another 30 days or until the 10th of the following month.

LSTA Fiscal Coordinator
Planning, Evaluation and Research
State Library of Ohio
274 East First Avenue, Suite 100
Columbus, OH 4301
FAX# (614) 466–3584
or email to: jward@sloma.state.oh.us