ETA 9130 (L) Financial Report Form, Indian and Native American Progra

Indian and Native American Program

U.S. DOL ETA FINANCIAL REPORT

(Follow instructions on the back.)

1.

Federal Agency and Organizational Element to Which Report is Submitted

2. Federal Grant or Other Identifying Number Assigned by DOL

OMB Approval No. 1205-0461

Expires 12/31/2015

3.

Recipient Organization (Name and complete address including Zip code)

4a.

Unique Entity Identifier

4b. EIN

5. Recipient Account Number or Identifying Number

6. Final Report

7. Basis of Reporting

□ Yes □ No

□ Accrual

8.

Project/Grant Period - From: (MM/DD/YYYY)

To: (MM/DD/YYYY)

9. Reporting Period End Date (MM/DD/YYYY)

10.

Transactions

Cumulative

Federal Cash:

a.

Cash Receipts

b.

Cash Disbursements

c.

Cash on Hand (line a minus b)

$-

Federal Expenditures and Unobligated Balance:

d.

Total Federal Funds Authorized

e.

Federal Share of Expenditures

f.

Total Administrative Expenditures

g.

Federal Share of Unliquidated Obligations

h.

Total Federal Obligations (sum of lines e and g)

$-

i.

Unobligated Balance of Federal Funds (line d minus h)

$-

Recipient Share:

j.

Total Recipient Share Required

k.

Recipient Share of Expenditures

l.

Remaining Recipient Share to Be Provided (line j minus k)

$-

Program Income:

m.

Total Program Income Earned

n.

Program Income Expended in Accordance with the Addition Method

o.

Unexpended Program Income (line m minus line n)

$-

11.

Additional Expenditure Data Required

a.

Other Federal Funds Expended

b.

Employment Services Expenditures

c.

Training Services Expenditures

d.

Other Program Services Expenditures

12.

Indirect Expenditures

a.

Type of Rate

b. Rate

c. Rate Approval Date

d. Period From (MM/DD/YYYY)

Period To (MM/DD/YYYY)

e. Base

f. Amount Charged

g. Federal Share

h. Totals:

$-

$-

$-

13.

Remarks: (Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation.)

14.

Certification: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729–3730 and 3801–3812).

a.

Typed or Printed Name and Title of Authorized Certifying Official

c. Telephone (Area code, number, and extension)

d. Email Address

b.

Signature of Authorized Certifying Official

e. Date Report Submitted (MM/DD/YYYY)

15. Agency Use Only:

Prescribed by OMB Uniform Guidance 2 CFR 200.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information, which is required to obtain or retain benefits (Pl 106-107, Sec 8), is estimated to average 45 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The reason for the collection of information is general program oversight, evaluation and performance assessment. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to ETA Office of Management and Administrative Services, Rm N-4653, U.S. Department of Labor, Washington DC 20210.

ETA-9130 (L)