FNS 778A Financial Status Report Addendum

FORM APPROVED OMB NO. 0584-XXXX
Expiration Date: XX/XXXX
1. FEDERAL AGENCY & ORGANIZATIONAL ELEMENT
TO WHICH REPORT IS SUBMITTED
FOOD AND NUTRITION SERVICE, USDA

FINANCIAL STATUS REPORT
ADDENDUM
2.
Letter of Credit No.
12-35-

3. STATE AGENCY (Name and complete address,including ZIP code)

2a. FISCAL YEAR
4. UNIVERSAL IDENTIFIER NO. 5. STATE AGENCY ACCOUNT NO. 6. FINAL REPORT
YES
NO
OR ID

7. BASIS
CASH

8. PROJECT/GRANT PERIOD

9. PERIOD COVERED BY THIS REPORT

FROM (Month, Day, Year)

FROM (Month, Day, Year)

TO (Month, Day, Year)

10. STATUS OF FUNDS

ACCRUAL

TO (Month, Day, Year)
SNAP
31
PROGRAM BENEFITS

FUNCTIONS/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 a 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
I. TOTAL CUMULATIVE AMOUNT OF FEDERAL FUNDS AUTHORIZED
m. UNOBLIGATED BALANCE OF FEDERAL FUNDS
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.

SIGNATURE OF AUTHORIZED
OFFICIAL
NAME

TITLE

DATE REPORT SUBMITTED

TELEPHONE NO.
AREA CODE

NUMBER

12. REMARKS: Attach any explanation deemed necessary or information required by FNS in compliance with governing
legislation.

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)

SBU

FORM FNS-778A (10-08)

Electronic Form Version Designed in Adobe 8.1 version

INSTRUCTIONS
FNS-778A

This form is used only to report the amount expended in program benefits for the Supplemental Nutrition Assistance Program
(SNAP) under any FNS approved project or initiative. Use a separate FNS-778A Addendum for each approved project or
initiative. Please type or print legibly. The fields and line items for items 1 through 10m are the same as those used on the
FNS-778. Directions for those line items may be found on the FNS-778. Specific instructions for column 31 are as follows:

31. PROGRAM BENEFITS: Enter in this Column the amount expended in program benefits for the Supplemental Nutrition
Assistance Program (SNAP) under any FNS approved project or initiative in which program benefits were authorized through a
grant award to the State agency and funded through the State Agency's Letter of Credit. Use a separate FNS-778 Addendum
for each type of project (e.g., SSI/Elderly Cash-out, Welfare Reform Initiative, Group Residential Housing Initiative, etc.) and
specify the type of project in the “Remarks” block.
DO NOT include program benefits in Columns 1 - 30 on the FNS-778.
According to the Paperwork Act of 1995, no persons are required to respond to a Collection of Information unless it displays a
valid OMB control number. The valid OMB control number is 0584-XXXX. The time required to complete this information
collection is estimated to average 1 hour per response, including the time to review instructions, search existing data sources,
gather the data needed, and complete and review the information collection.