(use the cursor keys or tab key to move between form fields)
1.	Organization name (Recipient):	     	
2.	Federal employer ID number:	     	
3.	Grant number:	     	
4.	Grant start date:	     	
5.	Funding closes on:	     	
6.	Period covered by this report:	From:      	To:      			
7.	Final request (yes, no):			
8.	This is request number (1, 2, 3, etc.):	 	
	
Computation of requested amount	
9.	Building name (abbreviate):	a.      	b.      	c.      	Total	
10.	Total outlays to date:	     	     	     	     	
11.	Recipient share of total outlays:	     	     	     	     	
12.	State share of total outlays:	     	     	     	     	
13.	Previous state payments:	     	     	     	     	
14.	State share now requested:
(line 15 minus line 16)	     	     	     	     	
	
15.	Remarks: 	     	
16.	Certification: 	I certify to the best of my knowledge and belief that this report is correct and complete and all outlays and unliquidated obligations were made in accordance with the grant conditions for the purposes set forth in the grant agreement, and payment is due and has not been previously requested.	
17.	Signature:		
18.	Printed name: 	     	
19.	Title:	     	
20.	Date:	     	
21.	Phone:	     	
Submit report to:	Chris Gukeisen, P.E.
South Dakota Energy Management Office
Joe Foss Building
523 E Capitol Avenue
Pierre, SD 57501-5981