Financial Status Report
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1(FEDERAL FORM)
FINANCIAL STATUS REPORT
(Short Form)
1.
Federal Agency and Organizational Element to which Report is
2.
Federal Grant or Other Identifying Number
OMB Approval
Page
of
Submitted
Assigned by Federal Agency
No.
pages
3.
Recipient Organization (Name and Complete address, including zip code)
4.
Employee Identification Number
5.
Recipient Account Number or
6.
Final Report
7.
Basic
Identifying Number
Yes
No
Cash
Accrued
9.
Period Covered by this Report
8.
Funding/Grant Period
From: (Month, Day , Year)
To: (Month, Day, Year)
From: (Month, Day, Year)
To: (Month, Day, Year)
/
/
/
/
/
/
/
/
10. Transactions:
I
II
III
Previously
This Period
Cumulative
Reported
a. Total Outlays
b. Recipient share of outlays
c. Federal share of outlays
d. Total unliquidated obligations
e. Recipient share of unliquidated obligations
f. Federal share of unliquidated obligations
g. Total Federal share (Sum of lines c and f)
h. Total Federal funds authorized for this funding period
i. Unobligated balance of Federal funds (Line h minus line g)
11. Indirect Expenses
a.
Type of Rate (Place X in appropriate box)
Provisional
Predetermined
Final
Fixed
b.
Rate
c.
Base
d.
Total Amount
e.
Federal Share
12. Remarks: attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation.
PROGRAM INCOME:
A. Block/Formula passthrough $
C. Forfeiture $
E. Expended $
B. Federal Funds subgranted $
D. Other
$
F. Unexpended $
13. Certification: I certify to the best of my knowledge and belief that this report is correct and complete and that all outlays and unliquidated obligations are for the
purposes set forth in the award documents.
Typed or Printed Name and Title
Telephone (Area Code, number and extension)
Signature of Authorized Certifying Official
Date Report Submitted
Standard Form 269A (Rev 4-88)
Described by OMB Circulars A102 and A-110
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