OSHS TCF OSHS Transmittal and Certification Form

U.S. DEPARTMENT OF LABOR

BUREAU OF LABOR STATISTICS

TRANSMITTAL AND CERTIFICATION FORM
FOR OSHS 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 673. 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 (1220-0149), 2 Massachusetts Avenue, NE, Room
4135, Washington, DC 20212-0001. You are not required to respond to the collection of information unless it displays a currently valid OMB control

OMB No. 1220-0149
Approval Expires: 05-31-2018

State Grant
Agency (SGA):
Check, or write in, the appropriate boxes:
SOII

CA#:

CFOI

Other

CA Period From:

To:

The following documents are being submitted for the closeout of the cooperative agreement indicated above.
(Check the appropriate boxes.)
Document Name
OSHS Financial Reconciliation Worksheet
SF-425 Federal Financial Report [Item 10 (lines d – k)
and item 11 (lines a – f)]
BLS-OSHS Quarterly Financial Report
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."
SGA Representative:
(type/print)

Title:

Authorized Signature:

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 OSHS TCF

Date: