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2. Instructions

   Welcome to the Sustainable Dubuque Grant reimbursement form. Before you start, please locate your SD Grant Acceptance Form. You will need the information on it to complete this form. 

   The SD Grant is reimbursement based so please also locate and scan your receipts into one document for easy uploading directly to this form. 

   SD Reimbursements occur at least quarterly (3/15; 6/10; 9/15; and 12/15), if not sooner.

   If you have questions or need assistance, please reach out to Gina Bell, 563.690.6038 or gbell@cityofdubuque.org for assistance.

4. Date of Request*
   Date of Request
6. Grantee*
   Name of person or organization requesting reimbursement.
8. Project Title *
10. City Council Approval Date*
    City Council Approval Date

    Found on grant acceptance form.

11. Resolution #*

    Found on grant acceptance form.

13. Project ID*

    Found on grant acceptance form.

14. PO #*

    Found on grant acceptance form.

16. Grant Award Amount ($)*

    Found on grant acceptance form.

20. Pay To:
    This information should match the W-9 you submitted at time of grant acceptance.
22. First Name
23. Last Name
25. Address1
27. City
28. State
29. Zip
33. Amount Requested for Reimbursement*

    $ amount

34. Are you requesting the entire grant amount?*
    -- Select One --Yes (final / only disbursement)No (additional disbursements will be requested)
36. Upload all grant related receipts here. *

    The Sustainable Dubuque Grant is reimbursement based and receipts are required for processing.

40. Reporting Requirements*

    Check one box only.

    1. Written report submitted via online form
    2. The project is not yet complete but I am requesting early payment.
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field