Fns-798a Addendum To Wic Financial Mangement And Participation Re

FORM APPROVED OMB NO. 0584-0045
Expiration Date: XX/XX/XXXX

U.S. DEPARTMENT OF AGRICULTURE - Food and Nutrition Service

ADDENDUM TO WIC FINANCIAL MANAGEMENT AND PARTICIPATION REPORT - NSA EXPENDITURES
Public reporting burden for this collection of information is estimated to average 1.7 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.
1. STATE AGENCY NAME

2. 7 - DIGIT CODE

3. PERIOD COVERED

4. FISCAL YEAR

STATE LEVEL EXPENDITURES

5. FUNCTIONS/
ACTIVITIES

01
PROGRAM
MGMT

LOCAL LEVEL EXPENDITURES
02
CLIENT
SERVICES

03
NUTRITION
EDUCATION

04
BREAST
FEEDING

05
PROGRAM
MGMT

06
CLIENT
SERVICES

07
NUTRITION
EDUCATION

08
BREAST
FEEDING

09
TOTAL

a. TOTAL FEDERAL
OUTLAYS
b. TOTAL STATE
OUTLAYS
(OPTIONAL)
6. INDIRECT EXPENSE AMOUNT:

Signature of Certifying Official

Name and Title

Date Report Submitted

Telephone Number
(Include Area Code)

REMARKS:

STAMP/CERTIFY DATE

LAST UPDATED BY

LAST UPDATED ON

FORM FNS-798 (9-11)
FPRS Electronic Version

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