Tribal Temporary Assistance for Needy Families (TANF) AC

OMB Control No. 1076-0135

Exp. Date: 11/30/2006

Tribal Temporary Assistance for Needy Families (TANF) ACF – 102-477 Financial Report 12g
TRIBE NAME	FISCAL YEAR			FISCAL YEAR ENDING DATE	Employer ID Number (EIN)
GRANT DOCUMENT NUMBER (BIA)
REPORTING ITEMS	(A) FEDERAL TFAG FUNDS			(B) TRIBAL FUNDS [OPTIONAL]*	(C) STATE CONTRIBUTED MOE FUNDS [OPTIONAL]
1. TOTAL AWARDED	$			$	$
2. CASH ASSISTANCE	$			$	$
3. OTHER ASSISTANCE EXPENDITURES	$			$	$
4. TOTAL NON-ASSISTANCE EXPENDITURES	$			$	$
5. ADMINISTRATION	$			$	$
6. SYSTEMS	$			$	$
7. OTHER EXPENDITURES	$			$	$
8. TRIBAL REPLACEMENT FUNDS				$
9. FEDERAL UNLIQUIDATED OBLIGATIONS	$
THIS IS TO CERTIFY THAT THE INFORMATION REPORTED ON ALL PARTS OF THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE
SIGNATURE: AUTHORIZED TRIBAL OFFICIAL		SUBMITTAL: [ ] NEW [ ] REVISED	TYPED NAME, TITLE, AGENCY NAME
DATE SUMITTED:
*Tribe must fill in Column (B) if it is subject to a penalty and corresponding reduction in its Tribal Family Assistance Grant (TFAG).
Data for lines 10 to 12 will be completed by the Federal Awarding Agency
REPORTING ITEMS	(A) FEDERAL TFAG FUNDS			(B) TRIBAL FUNDS [OPTIONAL]*	(C) STATE CONTRIBUTED MOE FUNDS [OPTIONAL]
10. TOTAL EXPENDITURES ON ASSISTANCE	$			$	$
11. TOTAL EXPENDITURES	$			$	$
12. FEDERAL UNOBLIGATED BALANCES	$

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