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FINANCIAL STATUS REPORT
1. FEDERAL AGENCY & ORGANIZATIONAL ELEMENT TO WHICH REPORT IS SUBMITTED
FOOD AND NUTRITION SERVICE, USDA
3. RECIPIENT ORGANIZATION (Name and
4. AGENCY DUNS NUMBER
complete address, including Zip code. Also enter
assigned State code.)
5. RECIPIENT ACCOUNT NUMBER OR
IDENTIFYING NUMBER
FEDERAL GRANT OR OTHER
NUMBER
2. FISCAL YEAR
6. FINAL REPORT
7. BASIS
Letter of Credit
No. 12-35-
YES
NO
8. PROJECT/GRANT PERIOD
10. STATUS OF FUNDS
CHILD AND ADULT CARE PROGRAM
1
MEAL SERVICE
PROGRAMS/FUNCTIONS/ACTIVITIES
2
SPONSOR
ADMIN.
3
AUDIT
CASH
SUMMER PROGRAM
4
START-UP
& EXPANSION
ACCRUAL
9. PERIOD COVERED BY THIS REPORT
5
CASH FOR
COMMODITIES
6
MEAL SERVICE
7
SPONSOR
ADMIN.
8
INSPECTION
ADVANCES
9
STATE ADMIN.
FUNDS
10
TOTAL
(Add Cols. 1, 2, 6 & 7)
a. Net outlays previously reported
b. Total outlays this report period
c. Less: Program Income credits
d. Net outlays this report period
(Line b minus line c)
e. Net outlays to date
(Line a plus line d)
f. Less: Non-Federal share of outlays
g. Total Federal share of outlays
(Line e minus line f)
h. Total unliquidated obligations
i. Less: Non-Federal share of unliquidated
obligations shown on line h
j. Federal share of unliquidated obligations
k. Total Federal share of outlays and
unliquidated obligations
l. Total cumulative amount of Federal
funds authorized
m. Unobligated balance of Federal funds
n. Advances Only
11. INDIRECT
EXPENSE
a. TYPE
b. RATE
c. PERIOD FROM
PERIOD TO
LAST UPDATED BY
LAST UPDATE ON
e. AMOUNT CHARGED
g. TOTALS
13. CERTIFICATION:
SIGNATURE OF AUTHORIZED CERTIFYING
I certify to the best of my
OFFICIAL
knowledge and belief that
this report is correct and
complete and that all outlays NAME
TITLE
and unliquidated obligations
are for the purposes set forth
in the award documents.
12. REMARKS: Attach any explanation deemed necessary or information required by Federal sponsoring agency
in compliance with governing legislation.
STAMP DATE
d. BASE
f. FEDERAL SHARE
DATE REPORT SUBMITTED
TELEPHONE NO.
AREA CODE NUMBER
No further monies or other benefits may be paid out under this program unless this
NOTE: When reordering this form specify "FNS-777 Child Nutrition"
report is completed and filed as required by existing regulation (34 C.F.R 256)
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis
(0584-0067), Alexandria, VA 22302. Do not return the completed form to this address.
FORM FNS-777 (06-11) Previous Editions Obsolete
SBU
Electronic Form Version Designed in Adobe 9.1 Version
Form Approved OMB. NO. 0584-0067
Expiration Date 12-31-2011
FINANCIAL STATUS REPORT
1. FEDERAL AGENCY & ORGANIZATIONAL ELEMENT TO WHICH REPORT IS SUBMITTED
FOOD AND NUTRITION SERVICE, USDA
3. RECIPIENT ORGANIZATION (Name and
4. AGENCY DUNS NUMBER
complete address, including Zip code. Also enter
assigned State code.)
5. RECIPIENT ACCOUNT NUMBER OR
IDENTIFYING NUMBER
FEDERAL GRANT OR OTHER
NUMBER
2. FISCAL YEAR
6. FINAL REPORT
7. BASIS
Letter of Credit
No. 12-35-
YES
8. PROJECT/GRANT PERIOD
10. STATUS OF FUNDS
SAE
11
SAE
PROGRAMS/FUNCTIONS/ACTIVITIES
12
SAE
(FD ONLY)
13
SPECIAL MILK
CASH
ACCRUAL
9. PERIOD COVERED BY THIS REPORT
SCHOOL PROGRAMS
14
SCHOOL LUNCH
NO
15
SCHOOL
BREAKFAST
16
SCH. CASH
FOR COMMOD.
17
SUMMER CASH
FOR COMMOD.
18
19
TOTALS
20
(Add Cols. 1-9, 11,
13-17)
a. Net outlays previously reported
b. Total outlays this report period
c. Less: Program Income credits
d. Net outlays this report period
(Line b minus line c)
e. Net outlays to date
(Line a plus line d)
f. Less: Non-Federal share of outlays
g. Total Federal share of outlays
(Line e minus line f)
h. Total unliquidated obligations
i. Less: Non-Federal share of unliquidated
obligations shown on line h
j. Federal share of unliquidated obligations
k. Total Federal share of outlays and
unliquidated obligations
l. Total cumulative amount of Federal
funds authorized
m. Unobligated balance of Federal funds
Enter amount federal outlays & unpaid obligations for special developmental
project funds used or obligated by program. (Amounts included in item k)
11. INDIRECT
EXPENSE
a. TYPE
b. RATE
SMP
c. PERIOD FROM
NSLP
PERIOD TO
LAST UPDATED BY
LAST UPDATE ON
CACFP
d. BASE
SFSP
e. AMOUNT CHARGED
g. TOTALS
13. CERTIFICATION:
SIGNATURE OF AUTHORIZED CERTIFYING
I certify to the best of my
OFFICIAL
knowledge and belief that
this report is correct and
complete and that all outlays NAME
TITLE
and unliquidated obligations
are for the purposes set forth
in the award documents.
12. REMARKS: Attach any explanation deemed necessary or information required by Federal sponsoring agency
in compliance with governing legislation.
STAMP DATE
SBP
f. FEDERAL SHARE
DATE REPORT SUBMITTED
TELEPHONE NO.
AREA CODE NUMBER
No further monies or other benefits may be paid out under this program unless this
NOTE: When reordering this form specify "FNS-777 Child Nutrition"
report is completed and filed as required by existing regulation (34 C.F.R 256)
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis
(0584-0067), Alexandria, VA 22302. Do not return the completed form to this address.
File Type | application/pdf |
File Title | Microsoft Word - 020609 Draft I- 312 Burden Statement.doc |
Author | rawagner |
File Modified | 2011-06-09 |
File Created | 2011-06-09 |