U. S. DEPARTMENT OF TRANSPORTATION, NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION
FEDERAL AID REIMBURSEMENT VOUCHER:            ( ) PROGRESS VOUCHER             ( ) FINAL VOUCHER


PAYEE NAME:_______________________________________ADDRESS_______________________________________________________


REIMBURSEMENT METHOD:             ( )ADVANCE (Fill in Advance Request Number Below)             ( )ELECTRONIC TRANSFER
                          ( )TREASURY CHECK - STATE IDENTIFICATION INFO:_________________________________________________


VOUCHER CONTROL NO:____________________________PERIOD OF CLAIM_______________________________________________

ADVANCE REQUEST NO:_____________________________PERIOD OF ADVANCE_______________________________________________


Program Area/
Project No.
Federal Funds
Obligated
Amount to Local
Benefit
Cumulative Total
cost toDate
Cumulative Federal
Funds Expended
Previous Amount
Claimed
Claimed This
Period












































TOTALS            


I CERTIFY, that in accordance with the laws of the State and under the terms of the program area(s) that actual costs claimed have been incurred and have not previously been presented for payment.

STATE OFFICIAL:

Name:_______________________________________
Title:__________________________________Date:__________

 

(APPROVAL AND PAYMENT ARE SUBJECT TO ADJUSTMENT, YEAR-END AUDIT OR OTHER APPROPRIATE REVIEW)

NHTSA APPROVAL:

Name:_________________________________________
Title:___________________________________Date___________



NOTE:   SEE DETAILED INSTRUCTIONS ON THE REVERSE SIDE


Revised 9/96




INSTRUCTIONS


( ) PROGRESS VOUCHER or              ( ) FINAL VOUCHER -- Place an X or Check mark in the appropriate parentheses.

PAYEE NAME -- Name of State Highway Safety Office.

ADDRESS -- Official Mailing address of State's Highway Safety Office

REIMBURSEMENT METHOD:      ( ) ADVANCE      ( ) ELECTRONIC TRANSFER      ( ) U.S. TREASURY CHECK [STATE IDENTIFICATION INFO] -- place an X or Check Mark in the appropriate parenthesis. For those States reimbursed with a U.S. Treasury check, provide specific information to appear on the check identifying it was issued for Highway Safety purposes.

VOUCHER CONTROL NO. --- the number should consist of seven spaces. The first four spaces are for the fiscal year, and the last three are for sequential numbering of the vouchers. EXAMPLE: 2000-001

PERIOD OF CLAIM -- enter the from and to dates (month, day, year).

PROGRAM AREA/PROJECT NUMBER -- this number can consist of six to ten spaces. The first two are the alpha abbreviation of the program area. The second two spaces are numeric and used for the fiscal year. The third two spaces are numeric values that represent the project number. The fourth two spaces are numberic values that represent the task number. The fifth two spaces are alpha/numeric that represent the sub-task number. EXAMPLE: PT-96-01-01-01

FEDERAL FUNDS OBLIGATED -- this represents Federal funds states have obligated for each program area/project, task, or sub-task. This is not to be confused with funds under project agreement.

AMOUNT TO LOCAL BENEFIT -- only required in the middle of the Fiscal Year or program period., whichever is closest to a six month interval and on Final Vouchers. That portion of the "Cumulative Federal Funds Expended", which represents funds spent by and/or for local government agencies.

CUMULATIVE TOTAL COST TO DATE -- this represents federal, state, and local cumulative costs. The State/Local cost portion represents the matching funds.

CUMULATIVE FEDERAL FUNDS EXPENDED -- this represents the cumulative amount of Federal funds States have requested for reimbursement to include the "Claimed This Period" on the voucher in hand.

PREVIOUS AMOUNT CLAIMED -- this represents the "Cumulative Federal Funds Vouchered" from the previous voucher submitted by the State to the Region.

CLAIMED THIS PERIOD -- this is the amount of Federal funds that state is currently requesting for reimbursement.

TOTALS -- total dollar figure for each column.

STATE CERTIFICATION -- where the pre-designated State official signs.

NHTSA APPROVAL -- where the NHTSA Regional approving official(s) signs.

NOTE: Any adjustments to the voucher need to be clearly identified in the appropriate column(s) and accompanied by an explanation.