Financial Status Report - Short Form

FINANCIAL STATUS REPORT
(Short Form)
(Follow instructions on the back)
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

0348-0038
pages
3. Recipient Organization (Name and complete address, including ZIP code)

4. Employer Identification Number

5. Recipient Account Number or Identifying Number 6. Final Report
Yes

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

To: (Month, Day, Year)

7. Basis
Cash

No

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

10. Transactions:

I
Previously
Reported

Accrual

To: (Month, Day, Year)

II
This
Period

III
Cumulative

a.

Total outlays

0.00

b.

Recipient share of outlays

0.00

c.

Federal share of outlays

0.00

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.

0.00

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

Type of Rate(Place "X" in appropriate box)

b.

Rate

Provisional

11. Indirect
Expense

c.

0.00
Predetermined

Base

d.

Total Amount

Final

Fixed

e.

Federal Share

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

legislation.

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

April 14, 2005
NSN 7540-01-218-4387

269-202

Standard Form 269A (Rev. 7-97)
Prescribed by OMB Circulars A-102 and A-110

FINANCIAL STATUS REPORT
(Short Form)
Public reporting burden for this collection of information is estimated to average 90 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget,
Paperwork Reduction Project (0348-0038), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Please type or print legibly. The following general instructions explain how to use the form itself. You may need additional information to
complete certain items correctly, or to decide whether a specific item is applicable to this award. Usually, such information will be found in
the Federal agency’s grant regulations or in the terms and conditions of the award. You may also contact the Federal agency directly.
Item

Entry

1, 2 and 3. Self-explanatory.
4. Enter the Employer Identification Number (EIN)
assigned by the U.S. Internal Revenue Service.
5. Space reserved for an account number or other
identifying number assigned by the recipient.

Item

Entry
the value of in-kind contributions applied, and the net
increase or decrease in the amounts owed by the recipient
for goods and other property received, for services
performed by employees, contractors, subgrantees and
other payees, and other amounts becoming owed under
programs for which no current services or performances are
required, such as annuities, insurance claims, and other
benefit payments.

6. Check yes only if this is the last report for the
period shown in item 8.

10b. Self-explanatory.

7. Self-explanatory.

10c. Self-explanatory.

8. Unless you have received other instructions from
the awarding agency, enter the beginning and
ending dates of the current funding period. If this is
a multi-year program, the Federal agency might
require cumulative reporting through consecutive
funding periods. In that case, enter the beginning
and ending dates of the grant period, and in the rest
of these instructions, substitute the term "grant
period" for "funding period."

10d. Enter the total amount of unliquidated obligations,
including unliquidated obligations to subgrantees and
contractors.

9. Self-explanatory.
10. The purpose of columns I, II, and III is to show the
effect of this reporting period’s transactions on
cumulative financial status. The amounts entered in
column I will normally be the same as those in
column III of the previous report in the same
funding period . If this is the first or only report of the
funding period, leave columns I and II blank. If you
need to adjust amounts entered on previous reports,
footnote the column I entry on this report and attach
an explanation.
10a. Enter total program outlays less any rebates,
refunds, or other credits. For reports prepared on a
cash basis, outlays are the sum of actual cash
disbursements for direct costs for goods and
services, the amount of indirect expense charged,
the value of in-kind contributions applied, and the
amount of cash advances and payments made to
subrecipients. For reports prepared on an accrual
basis, outlays are the sum of actual cash
disbursements for direct charges for goods and
services, the amount of indirect expense incurred,
*U. S. Government Printing Office: 1993 - 342-197/81289

Unliquidated obligations on a cash basis are obligations
incurred, but not yet paid. On an accrual basis, they are
obligations incurred, but for which an outlay has not yet
been recorded.
Do not include any amounts on line 10d that have been
included on lines 10a, b, or c.
On the final report, line 10d must be zero.
10e. f, g, h, h and i. Self-explanatory.
11a. Self-explanatory.
11b. Enter the indirect cost rate in effect during the reporting
period.
11c. Enter the amount of the base against which the rate was
applied.
11d. Enter the total amount of indirect costs charged during the
report period.
11e. Enter the Federal share of the amount in 11d.
Note: If more than one rate was in effect during the period shown
in item 8, attach a schedule showing the bases against
which the different rates were applied, the respective rates,
the calendar periods they were in effect, amounts of indirect
expense charged to the project, and the Federal share of
indirect expense charged to the project to date.
SF-269A (Rev. 7-97) Back