Sworn Statement Of Expenditures

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West Virginia Department of Health & Human Resources
SWORN STATEMENT OF EXPENDITURES
Grantee Name:
Grant Number:
Grantee FEIN: 
Contact Name:
wvOASIS Vendor #:
Contact Email Address:
Contact Phone:
Grantee Mailing Address:
Total Amount of Grant Award:
Grant Period:
Grant Revenues (received and anticipated)
Revenue Categories
Comments
Amount
Amount Received
Amount Anticipated
Total Grant Revenues
$0.00 
Grant Expenditures (allowable costs expended by the grantee)
Expenditure Categories
Comments
Amount
Personnel
Fringe Benefits
Equipment
Supplies
Contractual Costs
Construction
Other
Indirect Cost
Total Grant Expenditures 
$0.00 
Ending Grant Balance (Revenues – Expenditures) 
$0.00 
Grant Funds Returned to the DHHR
By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and accurate, and that the 
expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal 
(and/or State) award.  I am aware that any false, fictitious or fraudulent information, or the omission of any material fact, may 
subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise.  (U.S. Code Title 18, 
Section 1001 and Title 31, Sections 3729–3730 and 3801–3812).
Authorized Signature:
Date:
Printed Name and Title:
Taken, sworn and subscribed before me this____ day of ____________, 20____.
Notary Public Signature:  
My Commission Expires:
Revised May 2015

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