Financial Status Report - FNS 777

FORM APPROVED OMB NO. 0584-XXXX

Expiration Date XX-2011

FINANCIAL STATUS REPORT
3. RECIPIENT ORGANIZATION (Name and complete address, including

FEDERAL GRANT OR OTHER
NUMBER

1. FEDERAL AGENCY & ORGANIZATIONAL ELEMENT TO WHICH REPORT IS SUBMITTED

FOOD AND NUTRITION SERVICE, USDA
4. EMPLOYER IDENTIFICATION NUMBER

5. RECIPIENT ACCOUNT NUMBER OR

Letter of Credit
No 12-35-

6. FINAL REPORT

PROGRAMS/FUNCTIONS/ACTIVITIES

1
MEAL SERVICE

CHILD AND ADULT CARE PROGRAM

2
SPONSOR
ADMIN.

3
AUDIT

4
START-UP
& EXPANSION

5
CASH FOR
COMMODITIES

7. BASIS

___CASH
___ ACCRUAL
9. PERIOD COVERED BY THIS REPORT

8. PROJECT/GRANT PERIOD

10. STATUS OF FUNDS

2a. FISCAL YEAR

6
MEAL SERVICE

SUMMER PROGRAM

7
SPONSOR
ADMIN.

8
INSPECTION

9
STATE ADMIN.
FUNDS

ADVANCES

10
TOTAL
(Add Cols. 1,2,6 & 7)

a. Net outlays previously reported
b. Total outlays this report period
c. Less: Program Income credits
d. Net outlays this report period
(Line b minus line c)
e. Net outlays to date
(Line a plus line d)
f. Less: Non-Federal share of outlays
g. Total Federal share of outlays
(Line e minus line f)
h. Total unliquidated obligations
i. Less: Non-Federal share of unliquidated
obligations shown on line h
j. Federal share of unliquidated obligations
k. Total Federal share of outlays and
unliquidated obligations
l. Total cumulative amount of Federal
funds authorized
m. Unobligated balance of Federal funds
n. Advances Only
11. INDIRECT
EXPENSE

a. TYPE OF RATE
b. RATE

c. BASE

d. TOTAL AMOUNT

e. FEDERAL SHARE

12. REMARKS: Attach any explanation deemed necessary or information required by Federal sponsoring agency in
compliance with governing legislation.
STAMP DATE

LAST UPDATED BY

No further monies or other benefits may be paid out under this program unless this
report is completed and filed as required by existing regulation (34 C.F.R 256)

13. CERTIFICATION
SIGNATURE OF AUTHORIZED CERTIFYING
OFFICIAL
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.

LAST UPDATED ON

NOTE: When reordering this form specify "FNS-777 Child Nutrition "
Exception to SF-269. approved by NARS (11-80)

Electronic Form Version Designed in Adobe 8.1 Version

NAME

SBU

TITLE

DATE REPORT SUBMITTED

TELEPHONE NO.
AREA CODE NUMBER
Printed on
f

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis (0584-0067), Alexandria, VA 22302. Do not return the completed form to this address.

FORM APPROVED OMB NO. 0584-XXXX

Expiration Date XX-2011

FINANCIAL STATUS REPORT

FEDERAL GRANT OR OTHER
NUMBER

1. FEDERAL AGENCY & ORGANIZATIONAL ELEMENT TO WHICH REPORT IS SUBMITTED

FOOD AND NUTRITION SERVICE, USDA
3. RECIPIENT ORGANIZATION (Name and complete address, including

4. EMPLOYER IDENTIFICATION NUMBER

5. RECIPIENT ACCOUNT NUMBER OR

PROGRAMS/FUNCTIONS/ACTIVITIES

11
SAE

SAE

12
SAE

13
SPECIAL MILK

(FD ONLY)

___ ACCRUAL

9. PERIOD COVERED BY THIS REPORT

SCHOOL PROGRAMS

14
SCHOOL LUNCH

7. BASIS
___CASH

6. FINAL REPORT

8. PROJECT/GRANT PERIOD

10. STATUS OF FUNDS

2a. FISCAL YEAR

Letter of Credit

15
SCHOOL

16
SCH. CASH

17
SUMMER CASH

BREAKFAST

FOR COMMOD.

FOR COMMOD.

SBP

CACFP

SFSP

18

19

TOTALS
20

(Add Cols.1-9,11,13-17)

a. Net outlays previously reported
b. Total outlays this report period
c. Less: Program Income credits
d. Net outlays this report period
(Line b minus line c)
e. Net outlays to date
(Line a plus line d)
f. Less: Non-Federal share of outlays
g. Total Federal share of outlays
(Line e minus line f)
h. Total unliquidated obligations
i. Less: Non-Federal share of unliquidated
obligations shown on line h
j. Federal share of unliquidated obligations
k. Total Federal share of outlays and
unliquidated obligations
funds authorized
m. Unobligated balance of Federal funds
Enter amount federal outlays & unpaid obligations for special developmental
project funds used or obligated by program. (Amounts included in item k)
11. INDIRECT
a. TYPE OF RATE
EXPENSE
b. RATE
c. BASE

SMP

d. TOTAL AMOUNT

e. FEDERAL SHARE

12. REMARKS: Attach any explanation deemed necessary or information required by Federal sponsoring agency in
compliance with governing legislation.
STAMP DATE
LAST UPDATED BY
LAST UPDATED ON

No further monies or other benefits may be paid out under this program unless this
report is completed and filed as required by existing regulation (34 C.F.R 256)
NDB Electronic Version

NSLP

SIGNATURE OF AUTHORIZED CERTIFYING
13. CERTIFICATION
OFFICIAL
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.

NOTE: When reordering this form specify "FNS-777 Child Nutrition "
Exception to SF-269. approved by NARS (11-80)

Electronic Form Version Designed in Adobe 8.1 Version

NAME

SBU

TITLE

DATE REPORT SUBMITTED

TELEPHONE NO.
AREA CODE NUMBER
Printed on
Page 2 of 2

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis (0584-0067), Alexandria, VA 22302. Do not return the completed form to this address.