Form IA 7703 IA 7703 Financial Report

IA Form 7703 OMB Control No. 1076-0135 (Version 1)

Expiration Date: MM/DD/YYYY

P. L. 102-477 DEMONSTRATION PROJECT

FINAL FINANCIAL STATUS REPORT

(Follow instructions provided)

1. Federal Agency and Organizational Element to which Report is Submitted

2. Federal Contract or Other Identifying Number Assigned By Federal Agency

OMB Approval No. 1076-0135

Page

Of Pages

3. Recipient Organization (Name and complete address, including ZIP code)

4. Employer Identification Number

5. Recipient Account Number or Identifying Number

6. Final Report O YES O NO

7. Basis O CASH O ACCRUAL

8. Funding Contract Period (See Instructions) From: (Month/Day/Yr)

To: (Month/Day/Yr)

9. Period Covered by this Report From: (Month/Day/Yr)

To: (Month/Day/Yr)

10. Transactions:

I Previously Reported

II This Period

III Cumulative

a. Total outlays

b. Recipient share of outlays

c. Federal share of outlays

d. Total unliquidated obligations

e. Recipient share of unliquidated obligations

f. Federal share of unliquidated obligations

g. Total Federal share (Sum of lines c and f)

h. Total Federal funds authorized for this funding period

i. Unobligated balance of Federal funds (Line h minus line g)

11. Indirect

a. Type of Rate (Place an X in appropriate box) O Provisional O Predetermined O Final O Fixed

Expense

b. Rate

c. Base

d. Total Amount

e. Federal Share

12. Remarks: See instructions, Section 12 a. -g. for required and optional attachments. Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation.

13. Certification: I certify to the best of my knowledge and belief that this report is correct and complete and that all outlays and unliquidated obligations are for the purposes set forth in the award documents.

Typed or Printed Name and Title

Telephone (Area code, number and extension)

Signature of Authorized Certifying Official

Date Report Submitted

Instructions for Completing the

P.L. 102-477 Demonstration Project – Final Financial Status Report

Please type or print legibly. The following general instructions explain how to use the form itself. You may need additional information to complete certain items correctly or to decide whether a specific item is applicable to this award. Usually, such information will be found in the Federal agency’s grant regulations or in the terms and conditions of the award. You may also contact the Federal agency directly.

Item Entry Item Entry

1, 2 & 3 Self-explanatory.

4. Enter the employer identification number assigned by the U.S. Internal Revenue Service.

5. Space reserved for an account number or other identifying number assigned by the recipient.

6. Check yes only if this is the last report for the period shown in item 8.

7. Self-explanatory.

8. Unless you have received other instructions from the awarding agency, enter the beginning and ending dates of the current funding period. If this is a multi-year program, the Federal agency might require cumulative reporting through consecutive funding periods. In that case, enter the beginning and ending dates of the grant period, and in the rest of these instructions, substitute the term grant period for funding period.

9. Self-explanatory.

10. The purpose of columns I, II and III is to show the effect of this reporting periods transactions on cumulative financial status. The amounts entered in column I will normally be the same as those in column III of the previous report in the same funding period. If this is the first or only report of the funding period, leave columns I and II blank. If you need to adjust amounts entered on previous reports, footnote the column I entry on this report and attach an explanation. Do not include any DHHS Temporary Assistance to Needy Families (TANF) funds in this report.

10a. Enter total program outlays less any rebates, refunds or other credits. For reports prepared on a cash basis, outlays are the sum of actual cash disbursements for direct costs for goods and services, the amount of indirect expense charged, the value of in-kind contributions applied and the amount of cash advances and payments made to sub-recipients. For reports prepared on an accrual basis, outlays are the sum of actual cash disbursements for direct charges for goods and services, the amount of indirect expense incurred, the value of in-kind contributions applied and the net increase or decrease in the amounts owed by the recipient for goods and other property received, for services performed by employees, contractors, subgrantees and other payees and other amounts becoming owed under programs for which no current services or performances are required, such as annuities, insurance claims and other benefit payments.

10b. Self-explanatory.

10c. Self-explanatory.

10d. Enter the amount of unliquidated obligations, including unliquidated obligations to subgrantees and contractors.

Unliquidated obligations on a cash basis are obligations incurred, but not yet paid. On an accrual basis, they are obligations incurred, but for which an outlay has not yet been recorded. DO NOT include any amounts on line 10d that have been included on lines 10a, b or c. On the Final Report, line 10d must be zero.

10e.f.g.h & i Self-explanatory.

11a. Self-explanatory.

11b. Enter the indirect cost rate in effect during the reporting period.

11c. Enter the amount of the base against which the rate was applied.

11d. Enter the total amount of indirect costs charged during the report period.

11e. Enter the Federal share of the amount in 11d.

NOTE: If more than one rate was in effect during the period shown in Item 3, attach a schedule showing the bases against which the different rates were applied, the respective rates, the calendar periods they were in effect, amounts of indirect expense charged to the project and the Federal share of indirect expense charged to the project to date.

12. Please provide the following as attachments related to item 12.

12a. Certification that none of the funds in the approved budget which originated in the Workforce Investment Act (WIA) were used in violation of the Acts prohibition on the use of funds for economic development activities unless the tribe has approved economic development activities pursuant to Pub. L. 106-568 Section 1103.

12b. Certification that none of the funds in the approved budget which originated in the Workforce Investment Act (WIA) were used in violation of the Acts restrictions on assisting employer relocations.

12c. Amount of program income earned and purposes for which such income was expended.

12d. Amount of refunds or rebates received.

12e. Amount of funds expended for the category of the approved budget which includes administrative costs.

12f. Certification that Child Care Development Program Funds were used for appropriate Child Care Development funds related activities.

12g. Tribes with Department of Health and Human Services, Temporary Assistance to Needy Families funds within Pub. L. 102-477, are required to complete attachment 12g column A. Column B and C are optional.

Paperwork Reduction Act Statement: The information being collected meets the requirements of Public Law 102-477 for program evaluation, compliance, audit and program planning and management purposes. The data collected is shared with all participating Federal agencies providing funds. The reports are used to monitor the progress of the grantees in delivering services to tribal members, to identify unmet needs, to identify any other problems, and to provide information to justify budget submissions by the three federal agencies involved. Only tribes who have voluntarily applied to participate in this project will submit the annual report. Response is required to obtain benefits of the program. The report takes about 2 hours to complete. An agency may not request or sponsor a collection of information, and a person is not required to respond to a request, if a valid OMB control number is not provided. Comments concerning this information collection can be sent to: Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, Mail Stop 3071, Washington, DC 20240. Please note: comments, names and addresses of commenters are available for public review during regular business hours. If you wish us to withhold this information, you must state that prominently at the beginning of your comment. We will honor your request to the extent allowable by law.

OMB Control No. 1076-0135

Expiration Date: mm/dd/yyyy

NOTE: IA Form 7703 will be obsolete starting Month, Date, 2017