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pdfFORM APPROVED OMB NO. 0584-0045
Expiration Date: XX/XX/XXX
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 (0584-0045). Do not return the completed form to this
address.
STATE
LOC
FISCAL YEAR
REPORT MONTH/CALENDAR YEAR
DATE SUBMITTED
SEVEN DIGIT CODE
Food Obligation Estimates
DATA SIGNED
DATE RECEIVED IN R/O
LATEST REPORT MONTH AND REVISION
__
MONTHLY REPORT
__
ANNUAL CLOSEOUT REPORT
October
November
December
January
February
March
April
May
June
July
August
September
YTD Total
October
November
December
January
February
March
April
May
June
July
August
September
YTD Total
October
November
December
January
February
March
April
May
June
July
August
September
YTD Total
October
November
December
January
February
March
April
May
June
July
August
September
YTD Total
1. Adjusted Gross Obligations
2. Estimated Rebates
3. Net Federal Obligations
Actual Food Outlays
4. Gross Outlays
5. Unliquidated Obligations
6. Gross Outlays & Unliq
7. Rebates Received
8. Program Income
9. Postpymt Vendor Collections
10. Participant Collections
11. Other Credits
12. Net Federal Outlays & Unliq
13. Month Closed Out (Y/N)
14. Annual Net Federal Cost
Federal Participation
15. a. Women Pregnant
b. Women Fully Breastfeeding
c. Women Partially Breastfeeding
d. Women Postpartum
e. Total Women
16. a. Infants Fully Breastfed
b. Infants Partially Breastfed
c. Infants Fully Formula-fed
d. Total Infants
17. Children
18. Total
Year-to-Date NSA Costs
19. Gross Outlays
20. Unliquidated Obligations
21. Gross Outlays & Unliq
22. Program Income
23. Postpymt Vendor Collections
24. Participant Collections
25. Other Credits
26. Net Federal Outlays & Unliq
27. Est. Future Month(s) Oblig
28. Annual Net Fedral Cost
FORM FNS-798 (9-11)
FPRS Electronic Version
Page 1 of 2
Attachment 1
FORM APPROVED OMB NO. 0584-0045
WIC FINANCIAL MANAGEMENT AND PARTICIPATION REPORT
TRANSACTION
(A)
COST CATEGORY
(B)
(C)
FOOD
NSA
TOTAL
29. Formula Grant
30. Prior Year Spending Options
a. Spendforward from Prior Year
b. Backspend to Prior Year
31. Subtotal (29 plus 30)
32. Annual Net Federal Cost
33. Balance Before Application of Prepayment
Vendor Collections (31 minus 32)
34. Prepayment Vendor Collections Applied to NSA
35. Balance Before Conversion (33 plus 34)
36. Conversion
a. Food to NSA
b. NSA to Food
37. Balance After Conversion (35 plus 36)
38. Current Year Spending Options
a. Spendforward to Following Year
b. Backspend from Following Year
39. Results of Report Year Program
Operations (37 plus 38)
40. Preliminary Recoveries/Cash Transfers
a. Preliminary Recoveries
b. Cash Transfers in (out)
c. Total Recoveries/Cash Transfers
41. Federal Funds to be Recovered (Restored)
(39 plus 40c)
Explanatory Notes:
42. Funds Spent for Breast Pumps
43. Average Migrant Participation (July - June)
Remarks:
Certification
Typed Name and Title of Certifying Officer
I certify to the best of my knowledge and belief that
Signature
this report is correct and that all outlays and
unliquidated obligations are for the purposes set
Telephone Number
forth in the award document.
STAMP/CERTIFY DATE
LAST UPDATED BY
LAST UPDATED ON
FORM FNS-798 (9-11)
FPRS Electronic Version
Page 2 of 2
| File Type | application/pdf |
| File Modified | 2011-09-21 |
| File Created | 2011-09-21 |