Form BLS OSHS 2 BLS OSHS 2 BLS OSHS Quarterly Financial Report

BLS-OSHS QUARTERLY FINANCIAL REPORT BLS-OSHS2
State Grant Agency: _________________________________

OMB Approval No. 1220-0149; Expires 05-31-2015

Cooperative Agreement No.: ___________________ Reporting Period Ending: _______________
SECTION A – FINANCIAL ACTIVITY SUMMARY

Grant Program
Function
or Activity
(a)

Catalog of Federal
Domestic Assistance
Number
(b)

Expenditures for the Quarter
Federal
(c)

Cumulative Expenditures

Non-Federal
(d)

Federal
(e)

Non-Federal
(f)

Total
(g)

1.

$ 0.00

2.

$ 0.00

3.

$ 0.00

4.

$ 0.00

5. TOTALS

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

SECTION B -- TOTAL EXPENDITURES BY BUDGET CATEGORY FOR THE CURRENT QUARTER

GRANT PROGRAM, FUNCTION, OR ACTIVITY
6. Object Class Categories

(1)

(2)

(3)

TOTAL
(4)

(5)

a. Personnel

$ 0.00

b. Fringe Benefits

$ 0.00

c. Travel

$ 0.00

d. Equipment

$ 0.00

e. Supplies

$ 0.00

f. Contractual

$ 0.00

g. Construction

$ 0.00

h. Other

$ 0.00

i. Total Direct Charges (sum of 6a-6h)

$ 0.00

$ 0.00

$ 0.00

$ 0.00

j. Indirect Charges
k. TOTALS (sum of 6i and 6j)

$ 0.00
$ 0.00

$ 0.00

$ 0.00

$ 0.00

7. Program Income

$ 0.00

$ 0.00

$ 0.00

CERTIFICATION: I certify that to the best of my knowledge and belief the information provided above is accurate and complete, and was obtained from agency accounting records.

Authorized Signature: _________________________________________________________________________________________

Authorized for Local Reproduction

Date: ________________________

BLS-OSHS QUARTERLY FINANCIAL REPORTING FORM

GENERAL INSTRUCTIONS
This form is designed to capture actual expenditures for the quarter and cumulatively for the fiscal year. Reporting is separate by program activity, i.e., Annual Survey and CFOI,
and by object class categories. The report form parallels the Budget Information -- Non-Construction Programs form (SF-424A) and requires reporting by object class and
program activity quarterly, based on the projections by program and object provided in SF-424A at the time application is made for the Cooperative Agreement. A completed
original of this report is due in the BLS regional office no later than thirty days following the close of each quarter the agreement remains open, whether or not financial activity
took place within the reporting period.
SPECIFIC INSTRUCTIONS
Section A - Financial Activity Summary. Columns (a) and (b). Enter the abbreviated title of the program activity; i.e., SURVEY or CFOI, and the Catalog of Federal Domestic
Assistance number “17.005.”
Lines 1-4, Columns (c) and (d). Enter the Federal and Non-Federal expenditures for the current quarter for each program activity listed in Column (a).
Lines 1-4, Columns (e) and (f). Enter the Federal and Non-Federal expenditures for all quarters (including the current quarter) since the beginning of the agreement and the total
cumulative of Federal and Non-Federal expenditures in Column (g).
Section B - Total Expenditures by Budget Category. In column headings (1) through (4), enter the abbreviated titles of the same program activities shown on Lines 1-4,
Column (a), Section A. For each program activity, fill in the total expended (both Federal and Non-Federal combined), during the quarter, by object class categories in Lines 6a
through h.
Line 6i, Enter the total of Lines 6a through h for each column used.
Line 6j, Enter the amount of Indirect Cost.
Line 6k, Enter the total amounts of Lines 6i and 6j.
Line 7, Enter the amount of program income, if any, during the quarter.
CERTIFICATION
A duly authorized official of the State must sign and date the form. Only forms bearing an original signature will be valid and acceptable to the BLS.
PAPERWORK BURDEN STATEMENT
We estimate that it will taken an average of one hour 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 673. If you have any comments regarding this estimate or any other aspect of this form, including
suggestions for reducing this burden, please send them to the Bureau of Labor Statistics, Division of Financial Planning and Management (1220-0149), 2 Massachusetts Avenue, N.E., Room 4135, Washington,
D.C. 20212-0001. You are not required to respond to this collection of information unless it displays a currently valid OMB Approval Number.