BLS LMI TCF Transmittal and Certification Form

BUREAU OF LABOR STATISTICS

U.S. DEPARTMENT OF LABOR

TRANSMITTAL AND CERTIFICATION FORM
FOR LMI COOPERATIVE AGREEMENT CLOSEOUT DOCUMENTS
We estimate that it will take an average of 5-10 minutes to complete this form including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
information. Your response is required to obtain or retain benefits under 29 USC 49f(a)(3)(D). If you have any
comments regarding these estimates or any other aspect of this form, including suggestions for reducing this burden,
send them to the Bureau of Labor Statistics, Division of Financial Planning and Management (1220-0079), 2
Massachusetts Avenue, NE, Room 4135, Washington, DC 20212-0001. You are not required to respond to the
collection of information unless it displays a currently valid OMB control number.

OMB No. 1220-0079
Approval Expires 05-31-2015

State Workforce
Agency (SWA):
CA#:

CA Period From:

To:

The following documents are being submitted for the closeout of the cooperative agreement indicated above.
(Check the appropriate boxes under the column heading of either Partial Closeout or Final Closeout.)
Partial
Closeout

Final
Closeout

Document Name
LMI Financial Reconciliation Worksheet (2 Parts)
Financial Reports
Property Listing (if applicable)
HHS-PMS Account Balance Data Report
HHS-PMS Summary Grant Data Report
Other (Specify) ___________________________

"I certify, to the best of my knowledge and belief, that all information on this form is correct and complete. Further, all
information on all documents that accompany and constitute the cooperative agreement closeout package are correct and
complete. Finally, I certify, to the best of my knowledge and belief, that all program objectives, as delineated in the cooperative
agreement work statement(s), have been met."
SWA Representative:
(type/print)
Authorized Signature:

Title:
Date:

FOR THE BLS USE ONLY
Date Received in RO:

Received by:

Date Received in OFO:

Received by:

Date Received in DFPM:

Received by:

Approved by (Analyst, BGFM):
Remarks:

BLS LMI TCF

Date: