Reimbursement ChecklistReimbursement Checklist
Rev. 12/2019
REIMBURSEMENT CHECKLIST
HMA Grants
(HMGP / PDM / FMA)
Request for Funds:
Complete this form for each reimbursement according to the instructions on the second page of the form.
Invoice and Payment Summary:
Provide a spreadsheet that lists each invoice that has been paid by the sub-recipient. This spreadsheet should
contain all the information shown on the sample provided. It should be cumulative for all reimbursements with
a subtotal for each reimbursement request submitted.
Required Backup Documentation:
Proof of Costs (as applicable to the particular project)
Invoice from vendor/supplier that contains the following:
o Date/s of service
o Work performed
o Location or project that work was completed for
o Amount due
For construction projects:
o Contractor’s Application for Payment (Including continuation sheet)
o Certified Payroll for all dates worked on the project
Work Performed by Sub -Recipient Personnel
o A log of work performed (Sub-Recipient Payment Request Task Summary or Sub-Recipient Cost
Share Summary)
o Timecards showing hours attributable to the specific project
Third Party Cost Share Summary (if applicable)
Proof of Payment
Cancelled check for payment; or Municipal printout showing check paid; or signed warrant:
Proof of payment to employee (i.e. payroll reports).
Other documents that will be needed prior to release of funds:
Copies of all permits (if applicable)
Copies of all contracts with vendors/suppliers/contractors
Verification of procurement/bid process (to include, but not limited to, copies of bid specs, bid listing, Notice to
Proceed, narrative of selection process)
Copies of design and as-built plans (if applicable)
PLEASE NOTE THE FOLLOWING REQUIREMENTS:
The documentation above is required for both the 75% Federal Share being reimbursed AND the 25% Local
Share.
Refer to the Terms and Conditions sections “Request for Funds” and “Documentation Required for Release of
Funds” for further information.
Refer to 2 CFR Part 200 for eligibility of expenses.