Form SBA FORM 2113 SBA FORM 2113 PROGRAM INCOME REPORT

OMB Control Number: 3245-0169

Expiration Date: 6/30/2013

PROGRAM INCOME REPORT

(For SBDC Use Only)

Purpose: The Office of Small Business Development Centers (OSBDC) uses the SBA 2113 to track the sources and uses of program income. The form is to be attached to the SF 425 and submitted as required in the SBDC Notice of Award. This additional form is necessary as balances of program income for these awards may be carried over to subsequent years and may include several hundred thousand of additional funds earned and used each year. The total amount of program income must be monitored by SBA as there are limitations on the total program income balances that may be held by an entity.

SBDC NETWORK______________________________ PERIOD_________________________________

1. Net Program Income Carried Forward From the Prior Year(s) $____________________

2. Current Year Gross Program Income

SOURCE AMOUNT ($)

Training _________________________

Sales of Books, etc _________________________

Advertising _________________________

Research Work _________________________

Trade Shows _________________________

Other (Describe)

__­­­­­­___________________________ _______________________________

_____________________________ _______________________________

TOTAL CURRENT YEAR PROGRAM INCOME $______________________

3. Current Year Program Income Expenditures

EXPENSE CATEGORY AMOUNT

Personnel _________________________

Fringe _________________________

Consultants _________________________

Subcontracts _________________________

Travel _________________________

Equipment _________________________

Supplies _________________________

Other (Describe) _________________________

_________________________

_________________________

TOTAL CURRENT YEAR EXPENDITURES $ _____________________

4) Current Year Net Income (2-3) $ _____________________

5) Net Program Income Carried Forward to Following Year (1+4) $ ____________________

6) Narrative Description of how program income was used to further program objectives.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

By signing this report, I certify that it, and all information submitted with this report, is true and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent information may subject me to criminal penalties under 18 U.S.C. § 1001 and other statutes, and to other civil and administrative remedies as allowed by law. I further certify that all disbursements have been made in accordance with SBA requirements and that this institution maintains documentation supporting all information submitted to SBA.

NAME and TITLE________________________________________________ DATE: ________________

SIGNATURE__________________________________________________________________________

Paperwork Burden Statement: According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB control number for this information collection is 3245-0169. Public reporting burden for this collection of information is estimated to average 2 hours 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 (3245-0169), Washington, DC 20503

SBA Form 2113 (7-10) Previous Edition Obsolete