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 49L-1. 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
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OMB No. 1220-0079
Approval Expires XX-XXXXXX

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)
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 (Revised X XXXX)

Date: