Form None. Version 2 - Annual Financial Expenditure Report and Inst

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Overview

Tribe form
Tribe instructions

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Sheet 1: Tribe form

OMB Control No. 1076-0135		Expiration Date XX/XX/XXXX
U.S. Department of the Interior
Public Law 102-477
Annual Financial Expenditure Report (Version 2)
1. Tribe/Tribal Organization:		2. Other Identifying Number Assigned by DOI:
3. Mailing Address: (Provide complete mailing address)
4. Submission: (Mark One)		5. Final Report for Plan Period:
Original Revised		Yes No
6. Annual Report Period:		7. Plan Period Covered by this Report:
From:      /     /      To:      /     /		From:      /     /      To:      /     /
(Month/Day/Year) (Month/Day/Year)		(Month/Day/Year) (Month/Day/Year)
8. Transactions:	Column I: Previously Reported	Column II: This Annual Report Period	Column III: Cumulative/Total
a. Total Funds Available	$-	$-	$-
b. Cash Assistance Expenditures	$-	$-	$-
c. Child Care Services Expenditures	$-	$-	$-
d. Education, Employment, Training and Supportive Services Expenditures	$-	$-	$-
i. TANF Purposes 3 and 4 (non-add)	$-	$-	$-
ii. Other TANF Assistance (non-add)	$-	$-	$-
e. Program Operations Expenditures	$-	$-	$-
i. Child Care Quality Improvement (non-add)	$-	$-	$-
f. Administration/Indirect Cost Expenditures	$-	$-	$-
g. Total Federal Expenditures (Sum of lines b through f)	$-	$-	$-
h. Total Unexpended Funds	$	$	$
9. Certification: This is to certify that the information reported on all parts of this form is accurate and true to the best of my knowledge and belief and that the tribe has complied with all directly applicable statutory requirements and with those directly applicable regulatory requirements which have not been waived.
a. Signature of Tribal Official
b. Type Name and Title		c. Date Report Submitted
d. Questions regarding this report – Contact: (Type Name, Title, Phone #, and Email Address)

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Sheet 2: Tribe instructions

OMB Control No.		Expiration Date XX/XX/XXXX
U.S. Department of the Interior
Public Law 102-477
Annual Financial Expenditure Report - Instructions (Version 2)
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.
1. Enter the complete name of the Tribe or Tribal organization
2. Enter the Award or Grant number assigned by the Department of the Interior
3. Enter the complete mailing address of the Tribe or Tribal organization
4. Specify the status of this report submission; is this the original or a revised edition
5. Specify if this is the final financial report for the Plan Period. Mark “No” if this financial report includes funds that are unexpended. An Annual Report must be prepared and submitted for each Plan Period until all of the funds available for the Plan Period have been fully expended and reported. When the funds for the Plan Period have been fully expended, a final report for the Plan Period shall be submitted that notes the Total Unexpended Funds are zero.
6. Enter the beginning date (From) for the Annual Report Period and the date it ends (To). An Annual Report shall be prepared and submitted for each Plan Period until all of the funds available for the Plan Period have been fully expended and reported. For example, if there were Unexpended Funds at the end of the Plan Period from 10/01/2013 to 9/30/2016, for the Annual Report Period from 10/01/2016 to 9/30/2017 there would be a two reports. One report for the 10/01/2013 to 9/30/2016 Plan Period and one report for the 10/01/2016 to 9/30/2019 Plan Period.
7. Enter the beginning date (From) for this approved Pub. L. 102-477 Plan Period and the date it ends (To). This will usually be a three year period.
8. Transactions: The purpose of columns I, II and III is to show the effect of this Annual Report Period's transactions on cumulative financial status for the Plan Period. The amounts entered in column I will be the same as those in column III of the previous report in the same Plan Period. If this is the first or only report of the Plan Period, leave column I blank. Column II will reflect the transactions for this Annual Report Period and column III will be the total of columns I and II.
8.a: Enter the total of Federal funds available as of the Annual Report Period end date (i.e., funds awarded this period and carried over from previous periods within this Plan Period)
8. b-f: Refer to cost category definitions to determine appropriate placement of expenditure per category (see attached)
8. g: Enter the sum of lines b-f for the total Federal expenditures as of this Annual Report Period end date
8.h: Enter the total amount of funds not yet expended that will be carried over to the next Annual Report Period
9.a-d are self explanatory
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 will submit the annual report. Response is required to obtain benefits of the program. The report takes approximately 2 hours to complete. The requirements contained in this form have been reviewed and approved by the Office of Management and Budget (OMB) under the Paperwork Reduction Act , 44 U.S.C. 3504(h). An agency may not conduct or sponsor, and you are not required to respond to, any information collection that does not display a currently valid OMB Control Number. Comments concerning this information collection can be sent to: Information Collection Clearance Officer, Office of Regulatory Affairs - Indian Affairs, 1849 C Street, NW, Mailstop 3642, 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.