Form 4972 - Economic Vitality Incentive Program (Evip) Grant Financial Status Report (Fsr)

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Michigan Department of Treasury

Form 4972 (04-12)

Economic Vitality Incentive Program (EVIP) Grant Financial Status Report (FSR)

Completion is a condition of the grant under authority of Public Act 63 of 2011, as repealed and replaced by Public Act 278 of 2011.

SEE PAGE 2 FOR INSTRUCTIONS

PART 1: PROJECT INFORMATION

1. Grant Number

2. Project Title

3. Primary Local Unit Name

4. Telephone Number

5. Mailing Address

City

State

ZIP Code

6. Period Start Date

7. Period End Date

8. Report Type

10. Estimated Completion Date

9. Percentage Completed

Quarterly

Final

PART 2: FINANCIAL REPORTING

C. Projected Future

D. Total Projected

B. Amount Incurred to

E. Approved Original or

F. Difference Between

A. Budget Category

Expenditures to be

Expenditures for

Date

Amended Budget

Projection and Budget

Incurred

Project

11. Feasibility Study

12. Contracted Services

13. Administration

14. Training

15. Merger Expenses

16. Infrastructure/

Equipment

17. Other

18. ADJUSTMENTS DUE

TO OTHER FUNDING-

Reimbursements by other

(

) (

)

funding sources or the use of

cash on hand

19. TOTAL AMOUNTS-

Sum of amounts shown in

the column

PART 3: CERTIFICATION

I hereby certify that the information in this financial status report is complete and accurate and all expenditures which are presented are for eligible

scope items as defined in the Final Grant Award Letter for the above project, and that all expenditures have been made during the project period

as listed in the Final Grant Award Letter, and are identified and filed according to accounting procedures set forth by the Michigan Department of

Treasury.

Printed Name of Primary Local Unit Chief Financial Officer

Title

Signature of Primary Local Unit Chief Financial Officer

Date