Form Standard Form 269A Standard Form 269A Financial Status Report

FINANCIAL STATUS REPORT (Short Form)
1.
Federal Agency and Organizational
Element to Which Report is Submitted

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

OMB Approval
No.

Page of
Pages

0348-0039
3.

Recipient Organization (Name and complete address, including ZIP code)

4.

Employer Identification Number

8.
Funding/Grant Period (See Instructions)
From: (Month, Day, Year)

5.
Recipient Account Number or Identifying
Number

Transactions:

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
Expense

9.
Period Covered by this
Report
From: Month, Day, Year)

To: (Month, Day, Year)

10.

I
Previously Reported

Rate

c.

7.
Bas
[ ] Cash [ ] A

To:
Year)

II
This Period

0.00

a.
Type of Rate (Place "X" in appropriate box)
[ ] Provisional
[ ] Predetermined
b.

6.
Final
Report
[ ] Yes [ ] No

III
Cumul

0.00

[ ] Final
Base

(Mo

d.

[ ] Fixed
Total Amount

e.

Fed

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

13.
Certification
I certify to the best of my knowledge and belief that this report is correct and complete and that all outlays a
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

269-201
Standard Form 269A (REV 4-88)
NSN 7540-01-218-4387 Prescribed by OMB Circular A-102 and A-110