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Attachment 1 |
| FORM APPROVED OMB NO. 0584-0045 |
| U.S. DEPARTMENT OF AGRICULTURE - Food and Nutrition Service |
| WIC FINANCIAL MANAGEMENT AND PARTICIPATION REPORT |
| Public reporting burden for this collection of information is estimated to average 3.2367 hours 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 the burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research, Nutrition and Analysis, Alexandria, VA 22302 (0584-0054). Do not return the completed form to this address. |
| STATE |
LOC |
FISCAL YEAR |
REPORT MONTH/CALENDAR YEAR |
DATE SUBMITTED |
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| SEVEN DIGIT CODE |
DATA SIGNED |
DATE RECEIVED IN R/O |
LATEST REPORT MONTH AND REVISION |
__ MONTHLY REPORT |
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__ ANNUAL CLOSEOUT REPORT |
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| Food Obligation Estimates |
October |
November |
December |
January |
February |
March |
April |
May |
June |
July |
August |
September |
YTD Total |
| 1. Adjusted Gross Obligations |
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| 2. Estimated Rebates |
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| 3. Net Federal Obligations |
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| Actual Food Outlays |
October |
November |
December |
January |
February |
March |
April |
May |
June |
July |
August |
September |
YTD Total |
| 4. Gross Outlays |
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| 5. Unliquidated Obligations |
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| 6. Gross Outlays & Unliq |
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| 7. Rebates Billed |
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| 8. Program Income |
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| 9. Postpymt Vendor Collections |
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| 10. Participant Collections |
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| 11. Other Credits |
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| 12. Net Federal Outlays & Unliq |
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| 13. Month Closed Out (Y/N) |
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| 14. Annual Net Federal Cost |
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| Federal Participation |
October |
November |
December |
January |
February |
March |
April |
May |
June |
July |
August |
September |
YTD Total |
| 15. a. Women Pregnant |
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| b. Women Fully Breastfeeding |
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| c. Women Partially Breastfeeding |
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| d. Women Postpartum |
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| e. Total Women |
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| 16. a. Infants Fully Breastfed |
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| b. Infants Partially Breastfed |
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| c. Infants Fully Formula-fed |
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| d. Total Infants |
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| 17. Children |
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| 18. Total |
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| Year-to-Date NSA Costs |
October |
November |
December |
January |
February |
March |
April |
May |
June |
July |
August |
September |
YTD Total |
| 19. Gross Outlays |
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| 20. Unliquidated Obligations |
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| 21. Gross Outlays & Unliq |
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| 22. Program Income |
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| 23. Postpymt Vendor Collections |
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| 24. Participant Collections |
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| 25. Other Credits |
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| 26. Net Federal Outlays & Unliq |
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| 27. Est. Future Month(s) Oblig |
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| 28. Annual Net Fedral Cost |
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| FORM FNS-798 (7-02) |
Printed on 05/12/2008 10:12:24 AM |
| FPRS Electronic Version |
Page 1 of 2 |
| FORM APPROVED OMB NO. 0584-0045 |
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| WIC FINANCIAL MANAGEMENT AND PARTICIPATION REPORT |
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| TRANSACTION |
COST CATEGORY |
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| (A) |
(B) |
(C) |
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| FOOD |
NSA |
TOTAL |
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| 29. Formula Grant |
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| 30. Prior Year Spending Options |
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| a. Spendforward from Prior Year |
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| b. Backspend to Prior Year |
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| 31. Subtotal (29 plus 30) |
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| 32. Annual Net Federal Cost |
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| 33. Balance Before Application of Prepayment |
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| Vendor Collections (31 minus 32) |
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| 34. Prepayment Vendor Collections Applied to NSA |
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| 35. Balance Before Conversion (33 plus 34) |
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| 36. Conversion |
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| a. Food to NSA |
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| b. NSA to Food |
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| 37. Balance After Conversion (35 plus 36) |
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| 38. Current Year Spending Options |
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| a. Spendforward to Following Year |
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| b. Backspend from Following Year |
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| 39. Results of Report Year Program |
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| Operations (37 plus 38) |
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| 40. Preliminary Recoveries/Cash Transfers |
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| a. Preliminary Recoveries |
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| b. Cash Transfers in (out) |
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| c. Total Recoveries/Cash Transfers |
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| 41. Federal Funds to be Recovered (Restored) |
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| (39 plus 40c) |
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| Explanatory Notes: |
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| 42. Funds Spent for Breast Pumps |
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| 43. Average Migrant Participation (July - June) |
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| Remarks: |
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Certification
I certify to the best of my knowledge and belief that this report is correct and that all outlays and unliquidated obligations are for the purposes set forth in the award document. |
Typed Name and Title of Certifying Officer |
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| Signature |
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| Telephone Number |
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STAMP/CERTIFY DATE
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LAST UPDATED BY
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LAST UPDATED ON
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| FORM FNS-798 (7-02) |
Printed on 05/12/2008 10:12:24 AM |
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| FPRS Electronic Version |
Page 2 of 2 |
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