0120-FM-PO0223
Instructions
Rev. 4/2014
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
POLICY OFFICE
NATURAL GAS ENERGY DEVELOPMENT PROGRAM
ROUND 2 INSTRUCTIONS
STATEMENT OF EXPENDITURES
General
The Statement of Expenditures Form should be submitted to the Department of Environmental Protection (DEP) at
the following address:
DEP Grants Center
Location Code: 35GRNTCTR4
P.O. Box 69183
Harrisburg, PA 17106
In order for DEP to process the invoice, a copy of the Statement of Expenditures along with the following must be
submitted to the Project Advisor:
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Vehicle Master List Table with columns Q through U filled in for the vehicles purchased.
A copy of the invoice or the bill of sale that clearly shows the incremental cost or conversion cost.
Proof of payment from grantee and/or partner(s), as appropriate. This can be a copy of the front and back of
a cancelled check, wire transfer receipt, or an invoice indicating a zero balance due and receipt of payment in
full. For leased vehicles where the incremental purchase price is not paid as a separate one-time payment,
grantee must show proof of lease payments that equal or exceed the incremental purchase price.
A copy of a valid Pennsylvania vehicle registration. The name appearing on the vehicle registration must
appear on the invoice.
Proof of vehicle delivery.
Proof of EPA compliance of natural gas fueling system (copy of certificate, waiver or listing from EPA or
NGVA website).
For leased vehicles only, copy of lease agreement.
Signature from the grantee declaring the request for reimbursement to be true and accurate.
Ensure that a quarterly progress report is on file for the invoice period.
The time needed to process an invoice from the time the grantee submits the "Statement of Expenditures" until the
grantee can expect to receive payment from the commonwealth is approximately six to eight weeks. This time
estimate is based on the assumption that the form is properly completed. If changes are needed to the payment
request, the grantee should anticipate a longer timeframe.
Form Information
The grantee should refer to the Grant Agreement (specifically the Scope of Work) and the Vehicle Master List Table
when completing the Statement of Expenditures form. Include actual, not estimated, costs expended. Appropriate
receipts must be attached to the Vehicle Master List Table to document these costs.
Location Code – Always 35GRNTCTR4.
Invoice Date – Date that the grantee submits the invoice.
Invoice No. – Use the last five digits of the grant document number with a dash and the number of the invoice. For
example, if the Document number is 4100012345, the first invoice would be 12345-1, the second invoice would be
12345-2, etc. The final invoice would be 12345-FINAL.
Invoice Amount – Amount grantee is requesting to be reimbursed.
Project Title – Found on first page of Grant Agreement (Name of Project).
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0120-FM-PO0223
Instructions
Rev. 4/2014
Document # – Found on signature page of Grant Agreement.
Vendor # – Found on signature page of Grant Agreement.
Payable to (Grantee) – Found on first page of Grant Agreement.
Grantee Address – Grantee’s address.
Point of Contact – Grantee’s contact person.
Phone Number – Grantee’s telephone number.
Bank Routing Number – Nine-digit routing number for grantee’s bank.
Bank Account Number – Number for the account into which grantee would like reimbursement funds to be deposited.
Invoice Period – Grantee decides on the invoice period. It cannot fall outside the period of performance of the Grant
Agreement. Please indicate month, day and year that the work for which payment is requested was performed.
Expenditures Section
Total Grant Expenditures for this Period – The total amount of payment requested from the grant for the period
identified.
Percent Funds Expended – Leave this line blank.
Signature/Title/Date – The signature of an authorized representative for the grantee is required. A Statement of
Expenditures will not be processed without the proper declaration from the grantee.
Vehicle Master List Table
Each Statement of Expenditures must be accompanied by the Vehicle Master List Table with columns Q through U
filled in for the vehicles for which reimbursement is being requested. The current version must be submitted.
Q. This is the date for which the payment request is submitted for this vehicle.
R. Enter the Vehicle Identification Number (VIN).
S. Enter the Actual Total Incremental Purchase/Conversion Cost. This is the actual excess cost of a dedicated CNG
vehicle, a dedicated LNG vehicle or a bi-fuel vehicle over the price for a gasoline or diesel fuel motor vehicle of a
similar model, or the actual conversion cost.
T. Enter the Amount Requested for Reimbursement. This number cannot exceed Column M, which was the amount
agreed to when the Grant Agreement was executed.
U. Enter the Percentage of actual incremental cost = (Column T/ Column S) X 100 %. This number cannot exceed
Column N, which was the percentage agreed to when the Grant Agreement was executed.
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0120-FM-PO0223
Rev. 4/2014
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
POLICY OFFICE
SUBMIT FORM TO:
DEP Grants Center
Location Code 35GRNTCTR4
P.O. Box 69183
Harrisburg, PA 17106
Location Code: 35GRNTCTR4
Invoice Date:
Invoice No.:
Invoice Amount:
STATEMENT OF EXPENDITURES
(This section completed by DEP)
Document #
Date Received
Funding: NATURAL GAS ENERGY DEVELOPMENT
PROGRAM
Account Codes
$
$
Approved by:
Recommended for Payment $
Title:
Recommended for Payment
Director, DEP Grants Center
Date Approved:
Project Advisor’s Initials
Date Recommended:
(This section completed by Grantee)
Project Title:
Document #
Vendor #
Payable To (Grantee):
Grantee Address:
Point of Contact:
Phone Number:
Bank Routing #:
Bank Account #:
Invoice Period:
, 20
(Indicate month, day and year that work was performed.)
to
,
20
EXPENDITURES:
TOTAL REQUESTED GRANT EXPENDITURES FOR ABOVE PERIOD: $
Percent Funds Expended (DEP Grants Center Will Complete):
%
(DEP Use Only)
All related backup to this invoice is being held at
for audit purposes
GRANTEE SIGNATURE:
I declare the above to be a true and accurate statement.
Signature
Title
Date
Note: Please provide:

A copy of the invoice or the bill of sale that clearly shows the incremental cost or conversion cost.

Proof of payment by the grantee or project partner(s). This can be a copy of the front and back of a cancelled check, wire transfer
receipt, or an invoice indicating a zero balance due and receipt of payment in full. For leased vehicles where the incremental purchase
price is not paid as a separate one-time payment, grantee must show proof of lease payments that equal or exceed the incremental
purchase price.

A copy of a valid Pennsylvania vehicle registration. The name appearing on the vehicle registration must appear on the invoice.

Proof of EPA compliance of natural gas fueling system (copy of certificate, waiver or listing from EPA or NGVA website).

For leased vehicles only, copy of lease agreement must be provided.

Proof of vehicle delivery