Federal Financial Report

FEDERAL FINANCIAL REPORT

(Follow form instructions)

1. Federal Agency and Organizational Element to Which

2. Federal Grant or Other Identifying Number Assigned by Federal Agency (To

Page

of

Report is Submitted

report multiple grants, use FFR Attachment)

1

pages

3. Recipient Organization (Name and complete address including Zip code)

4a. DUNS Number

4b. EIN

5. Recipient Account Number or Identifying

6. Report Type

7. Basis of Accounting

Number (To report multiple grants, use FFR

Quarterly

Cash

Attachment)

Accrual

Semi-Annual

Annual

Final

8. Project/Grant Period (Month, Day, Year)

9. Reporting Period End Date (Month, Day, Year)

From:

To:

10. Transactions

Cumulative

(Use lines a-c for single or combined multiple grant reporting)

Federal Cash (To report multiple grants separately, also use FFR Attachment):

a. Cash Receipts

b. Cash Disbursements

c. Cash on Hand (line a minus b)

(Use lines d-o for single grant reporting)

Federal Expenditures and Unobligated Balance:

d. Total Federal funds authorized

e. Federal share of expenditures

f. Federal share of unliquidated obligations

g. Total Federal share (sum of lines e and f)

h. Unobligated balance of Federal funds (line d minus g)

Recipient Share:

i. Total recipient share required

j. Recipient share of expenditures

k. Remaining recipient share to be provided (line i minus j)

Program Income:

l. Total Federal share of program income earned

m. Program income expended in accordance with the deduction alternative

n. Program income expended in accordance with the addition alternative

o. Unexpended program income (line l minus line m or line n)

11.

a. Type

b. Rate

c. Period

Period To

d. Base

e. Amount Charged

f. Federal Share

Indirect

From

Expense

g. Totals:

12. Remarks: Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:

13. Certification: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the

expenditures, disbursements and cash receipts are for the purposes and intent set forth in the award documents. I am aware that any false,

fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)

a. Typed or Printed Name and Title of Authorized Certifying Official

c. Telephone (Area code, number, and extension)

d. Email Address

b. Signature of Authorized Certifying Official

e. Date Report Submitted (Month, Day, Year)

14. Agency use only:

Standard Form 425 - Revised 10/11/2011

OMB Approval Number: 0348-0061

Expiration Date: 2/28/2015

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