SF 269 (Food Stamp) 7-2003

FORM APPROVED OMB NO. 0348-0039

FINANCIAL STATUS REPORT

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

FEDERAL GRANT OR OTHER NUMBER

2a. FISCAL YEAR

FOOD AND NUTRITION SERVICE, USDA

Letter of Credit No. 12-35-

3. RECIPIENT ORGANIZATION (Name and complete address, including      ZIP code. Also enter assigned State code.)

4. UNIVERSAL IDENTIFIER NUMBER

5. RECIPIENT ACCOUNT NUMBER OR     IDENTIFYING NUMBER

6. FINAL REPORT

7. BASIS

___CASH        ___ ACCRUAL

8. PROJECT/GRANT PERIOD

9. PERIOD COVERED BY THIS REPORT

10. STATUS OF FUNDS

FOOD STAMP PROGRAM

1

2

3

4

5

6

7

8

9

10

PROGRAMS/FUNCTIONS/ACTIVITIES

CERTIFICATION

COUPON

PERFORMANCE

REPORTING

50% FUNDING

75% FUNDING

ADP OPER

FAIR

OTHER

TOTAL

ISSUANCE

QUAL. CNTL.

MGT.EVAL.

FRAUD CNTL.

FRAUD CNTL.

HEARINGS

ACTIVITIES

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

11. INDIRECT

a. TYPE OF RATE     ___PROVISIONAL           ___ PREDETERMINED           ___ FINAL             ___ FIXED

13. CERTIFICATION

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE REPORT SUBMITTED

EXPENSE

b. RATE

c. BASE

d. TOTAL AMOUNT

e. FEDERAL SHARE

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.

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

NAME

TITLE

TELEPHONE NO.

AREA CODE

NUMBER

-

No further monies or other benefits may be paid out under this program unless this

NOTE: When reordering this form specify "SF-269 FOOD STAMP "

STANDARD FORM 269 (7-03) (FOOD STAMP)

report is completed and filed as required by existing regulation (34 C.F.R 256)

Exception to SF-269. approved by NARS (11-80)

Printed on

NDB Electronic Version

Page 1 of 4

FORM APPROVED OMB NO. 0348-0039

FINANCIAL STATUS REPORT

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

FEDERAL GRANT OR OTHER NUMBER

2a. FISCAL YEAR

FOOD AND NUTRITION SERVICE, USDA

Letter of Credit No. 12-35-

3. RECIPIENT ORGANIZATION (Name and complete address, including      ZIP code. Also enter assigned State code.)

4. UNIVERSAL IDENTIFIER NUMBER

5. RECIPIENT ACCOUNT NUMBER OR     IDENTIFYING NUMBER

6. FINAL REPORT

7. BASIS

___CASH        ___ ACCRUAL

8. PROJECT/GRANT PERIOD

9. PERIOD COVERED BY THIS REPORT

10. STATUS OF FUNDS

FOOD STAMP PROGRAM

11

12

13

14

15

16

17

18

19

20

PROGRAMS/FUNCTIONS/ACTIVITIES

E&T

E&T

E&T

E&T

OPTIONAL

NUTRITION

PAGE 2

100% GRANT

50% GRANT

DEPENDENT CARE

TRANS. & OTHER

WORKFARE

OUTREACH

EDUCATION

REINVESTMENT

SAVE

SUBTOTAL

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

11. INDIRECT

a. TYPE OF RATE     ___PROVISIONAL           ___ PREDETERMINED           ___ FINAL             ___ FIXED

13. CERTIFICATION

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE REPORT SUBMITTED

EXPENSE

b. RATE

c. BASE

d. TOTAL AMOUNT

e. FEDERAL SHARE

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.

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

NAME

TITLE

TELEPHONE NO.

AREA CODE

NUMBER

-

No further monies or other benefits may be paid out under this program unless this

NOTE: When reordering this form specify "SF-269 FOOD STAMP "

STANDARD FORM 269 (7-03) (FOOD STAMP)

report is completed and filed as required by existing regulation (34 C.F.R 256)

Exception to SF-269. approved by NARS (11-80)

Printed on

NDB Electronic Version

Page 2 of 4

FORM APPROVED OMB NO. 0348-0039

FINANCIAL STATUS REPORT

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

FEDERAL GRANT OR OTHER NUMBER

2a. FISCAL YEAR

FOOD AND NUTRITION SERVICE, USDA

Letter of Credit No. 12-35-

3. RECIPIENT ORGANIZATION (Name and complete address, including      ZIP code. Also enter assigned State code.)

4. UNIVERSAL IDENTIFIER NUMBER

5. RECIPIENT ACCOUNT NUMBER OR     IDENTIFYING NUMBER

6. FINAL REPORT

7. BASIS

___CASH        ___ ACCRUAL

8. PROJECT/GRANT PERIOD

9. PERIOD COVERED BY THIS REPORT

10. STATUS OF FUNDS

FOOD STAMP PROGRAM

21

22

23

24

25

26

27

28

29

30

PROGRAMS/FUNCTIONS/ACTIVITIES

50% FUNDING

63% FUNDING

75% FUNDING

EBT

ISSUANCE

EBT

UNSPECIFIED

E&T

PAGE 3

ADP DEV.

ADP DEV.

ADP DEV.

ISSUANCE

INDIRECT

STARTUP

PORTION OF OTHER

ABAWD GRANT

SUBTOTAL

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

11. INDIRECT

a. TYPE OF RATE     ___PROVISIONAL           ___ PREDETERMINED           ___ FINAL             ___ FIXED

13. CERTIFICATION

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE REPORT SUBMITTED

EXPENSE

b. RATE

c. BASE

d. TOTAL AMOUNT

e. FEDERAL SHARE

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.

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

NAME

TITLE

TELEPHONE NO.

AREA CODE

NUMBER

-

No further monies or other benefits may be paid out under this program unless this

NOTE: When reordering this form specify "SF-269 FOOD STAMP "

STANDARD FORM 269 (7-03) (FOOD STAMP)

report is completed and filed as required by existing regulation (34 C.F.R 256)

Exception to SF-269. approved by NARS (11-80)

Printed on

NDB Electronic Version

Page 3 of 4

FORM APPROVED OMB NO. 0348-0039

FINANCIAL STATUS REPORT

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

FEDERAL GRANT OR OTHER NUMBER

2a. FISCAL YEAR

FOOD AND NUTRITION SERVICE, USDA

Letter of Credit No. 12-35-

3. RECIPIENT ORGANIZATION (Name and complete address, including      ZIP code. Also enter assigned State code.)

4. UNIVERSAL IDENTIFIER NUMBER

5. RECIPIENT ACCOUNT NUMBER OR     IDENTIFYING NUMBER

6. FINAL REPORT

7. BASIS

___CASH        ___ ACCRUAL

8. PROJECT/GRANT PERIOD

9. PERIOD COVERED BY THIS REPORT

10. STATUS OF FUNDS

FOOD STAMP PROGRAM

31

32

PROGRAMS/FUNCTIONS/ACTIVITIES

BENEFIT

ENHANCED

DATA

FUND-QC

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

11. INDIRECT

a. TYPE OF RATE     ___PROVISIONAL           ___ PREDETERMINED           ___ FINAL             ___ FIXED

13. CERTIFICATION

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE REPORT SUBMITTED

EXPENSE

b. RATE

c. BASE

d. TOTAL AMOUNT

e. FEDERAL SHARE

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.

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

NAME

TITLE

TELEPHONE NO.

AREA CODE

NUMBER

-

No further monies or other benefits may be paid out under this program unless this

NOTE: When reordering this form specify "SF-269 FOOD STAMP "

STANDARD FORM 269 (7-03) (FOOD STAMP)

report is completed and filed as required by existing regulation (34 C.F.R 256)

Exception to SF-269. approved by NARS (11-80)

Printed on

NDB Electronic Version

Page 4 of 4