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Legislative Member Item Program Forms

All Legislative Member Item Program (MIP) forms are available for download by award recipients. Forms are available in either PDF or OmniForm format. Please refer to the Legislative Member Item Program Manual for further information on each form.

Program Forms:

Application for Funds
Certificate of Hardship
Conflict of Interest Form (NPP/RPP/MIP)
Disbursement Request Form for Contracts/Voucher Agreements over $25,000
Standard Voucher (Claim Form Payment)
Final Report Forms:

Final Report (for vouchers less than $50,000)
Final Report (for contracts $50,000 and over)

Contract Documents:

Contract: State of NY Agreement
Contract Face Page | Word file format
Contract Signature Page
Appendix A: Standard Clauses for All New York State Contracts
Appendix A-1 MIP: Agency-Specific Clauses - Member Item Program
Appendix A1A: Additional Contract Language
Appendix A2: Description of Neighborhood/Area Boundaries
Appendix B: Budget
Appendix C: Payment and Reporting Schedule
Appendix D: Work Plan
Vendor Responsilibilty Questionnaire
Appendix X: Modification Agreement
Certification Appendix under $50,000
Certification Appendix $50,000 and Above
Insurance Requirements

Last updated on 12/14/12

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Interest Rate: 3.500%*