ETA 9130 F Local Dislocated Worker

Workforce Innovation and Opportunity Act - Local Dislocated Worker

U.S. DOL ETA FINANCIAL REPORT
(Follow instructions on the back.)
1. Federal Agency and Organizational Element to Which Report is Submitted

OMB Approval No. 1205-0461

2. Federal Grant or Other Identifying Number Assigned by DOL

Expires 04/30/2019
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
8. Project/Grant Period From: (MM/DD/YYYY)

To: (MM/DD/YYYY)

□ Accrual

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

10. Transactions
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.
a.
b.
c.
d.
e.
f.
g.

Cumulative

Additional Obligation and Expenditure Data Required
Other Federal Funds Expended
Real Property Proceeds Expended
Expenditure of Dislocated Worker Funds on the Adult Program
Federal Share of Unliquidated Obligations for Pay-for-Performance Contracts
Pay-for-Performance Contract Expenditures
Transitional Jobs Expenditures
Incumbent Worker Training Expenditures

12. Remarks: (Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation.)
13. 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)
14. 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 (2 CFR 200.327 and WIOA Section 185(e)(2)), 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 (F)

U.S. Department of Labor Employment and Training Administration
Financial Report Instructions

ETA-9130 (F) – Local Dislocated Worker
There are different variations of form ETA-9130, each pertaining to a specific program/funding stream.
The instructions for the various ETA-9130 forms are not identical.
Please ensure that you are using the correct ETA-9130 form and instructions.
Report Submission
1)

The U.S. Department of Labor (DOL) Employment and Training Administration (ETA) requires all grant recipients to submit the ETA-9130
Financial Report electronically through an on-line reporting system.

2)

Recipients are issued a password and a PIN to enable reporting via the on-line reporting system at www.etareports.doleta.gov. Upon
accessing the system, detailed on-line reporting instructions are provided.

3)

Report submission is a three step process:
1.
2.
3.

DATA ENTRY – the Secondary Contact person, designated by the recipient organization, is responsible for entering the required
data on the ETA-9130, using the password;
DATA CERTIFICATION – the Primary Contact person, the designated authorized official in the recipient organization, is
responsible for certifying the accuracy of the data by entering the PIN; and
DATA ACCEPTANCE – DOL/ETA is responsible for reviewing the certified ETA-9130, communicating with recipients, as
necessary, and accepting the report within 10 working days after report certification. If a modification is required, the certification
and acceptance processes must be repeated.

Reporting Requirements
1)

Submission of the ETA-9130 is required on a quarterly basis. Reporting quarter end dates shall correspond to the following calendar
quarter end dates: March 31, June 30, September 30, and December 31. A final quarter ETA-9130 is required at the completion of the
quarter, encompassing the grant award end date, or at the completion of the quarter in which all funds have been expended, whichever
comes first. The final quarter ETA-9130 must be indicated by selecting “YES” in Item 6, Final Report.

2)

Quarterly reports, including the final quarter report, are required to be submitted no later than 45 calendar days after the end of each
specified reporting period. The reporting due dates are: May 15, August 14, November 14, and February 14. The deadlines for ETA9130 submissions do not change, even in instances when the reporting due date falls on a weekend or holiday. The e-reporting system is
available 24 hours a day, 7 days a week, and reports can be submitted in advance of the due date. However, technical support is
available only during normal business hours (EST), Monday through Friday.

3)

A closeout report is required to be submitted no later than 90 calendar days after the grant end date. The closeout report is separate
from (and additional to) the final quarter report and becomes accessible on-line after submittal of the final quarter report. (The closeout
report does not need to be completed until the grant closeout process begins.)

4)

All financial data is required to be reported cumulative from grant inception, through the end of each reporting period. Expenditure data
is required to be reported on an accrual basis.

5)

A separate ETA-9130 is required for each program and each fund source awarded to a grant recipient.

6)

All sections of the report must be completed unless otherwise noted in the grant agreement.

For more information regarding DOL/ETA grants and financial reporting, please visit http://www.doleta.gov/grants/. Additional assistance may be
provided through your Federal Project Officer. Technical issues with the on-line reporting system should be directed to:
[email protected].
Please ensure that the certifying official information contained in Items 13a -13d is correct. Any outdated information will delay transmission of
the grant’s closeout package and relevant information affecting the grant. To request a change in the signatory/certifying official, you must
send an e-mail to [email protected].

Financial Report Instructions

Line Item
Number

ETA-9130 (F) – Local Dislocated Worker

Reporting/Line Item

Instructions

1

Federal Agency and Organizational
Element to Which Report is Submitted

2

Federal Grant or Other Identifying
Number Assigned by DOL

3

Recipient Organization

4a

Unique Entity Identifier

4b

EIN

5

Recipient Account Number or
Identifying Number

6

Final Report
(Yes/No)

“U.S. Department of Labor Employment & Training Administration.”
PRE-ENTERED
Grant number assigned for the award by DOL/ETA and contained on the grant award
document. Also called Federal Award Identification Number (FAIN) under the Uniform
Guidance (2 CFR 200).
PRE-ENTERED
Name and complete address of recipient organization.
PRE-ENTERED
Recipient organization’s Unique Entity Identifier, currently known as the Data Universal
Numbering System (DUNS) number or Central Contractor Registry extended DUNS number
until such time a Unique Entity Identifier (UEI) is determined.
PRE-ENTERED
Recipient organization’s Employer Identification Number (EIN). Also known as the Federal
Employer Identification Number (FEIN), or the Federal Tax Identification Number, the EIN is
a unique nine-digit number assigned by the Internal Revenue Service (IRS) to business
entities operating in the United States for the purpose of identification.
PRE-ENTERED
Enter the account number or any other identifying number assigned by the recipient to the
grant award. This number is strictly for the recipient’s use and is not required by
DOL/ETA.
Select appropriate box. Check “Yes” only if this is the final quarter report for subject grant.
The grant closeout will not occur until after the grant end date.
ACCRUAL has been pre-entered on all ETA-9130 reports.

Cover Information

DOL/ETA regulations require that all recipients report expenditures and program
income on an accrual basis. For accrual basis reporting, accrued expenditures are
recorded when a requirement to pay is established.
7

Basis of Reporting
(Accrual)

Project/Grant Period, From:
(MM/DD/YYYY)
8

9

Project/Grant Period, To:
(MM/DD/YYYY)
Reporting Period End Date:
(MM/DD/YYYY)

NOTE: Uniform Guidance, 2 CFR 2900.14: “In addition to the guidance set forth in 2 CFR
200.327, for Federal awards from the Department of Labor, the DOL awarding agency will
prescribe whether the report will be on a cash or an accrual basis. If the DOL awarding
agency requires reporting on an accrual basis and the recipient’s accounting system is not
on the accrual basis, the recipient will not be required to convert its accounting system, but
must develop and report such accrual information through best estimates based on an
analysis of the documentation on hand.”
The beginning date of the grant award as defined in the grant award document.
PRE-ENTERED
The ending date of the grant award as defined in the grant award document, and the final
date for which any accrued expenditures can be incurred under the subject grant award.
PRE-ENTERED
The last date of the quarter for which cumulative data is provided on the subject ETA-9130.
(Required reporting quarter end dates are contained in the “Reporting Requirements” in the
first section of these instructions.)
PRE-ENTERED

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Financial Report Instructions
Line Item
Number

Reporting/Line Item

ETA-9130 (F) – Local Dislocated Worker
Instructions

Transactions
Enter cumulative amounts in the Cumulative Column for each line item requiring data entry, as of the reporting period end date.
NOTE: If any line item does NOT require data entry for a particular grant/program, a ZERO must be entered.
10

Line items which will be automatically calculated are grayed out, and no data entry will be permitted by the reporting entity.
Cumulative data for the current reporting quarter will become the Previous Period Column in the following quarter. This Period data
will be automatically calculated. Use Section 12, Remarks, to provide any information deemed necessary to support/explain data
provided in this section.

Federal Cash
Enter the cumulative amount of actual cash received from the Federal agency as of the
reporting period end date. Cash received means cash deposited in your bank account.
Drawdowns initiated on the last business day of a quarter should NOT be reflected in this
amount, but in the subsequent quarter’s cash receipts.
Cumulative drawdowns posted in the Payment Management System (PMS) through the end
of the reporting period end date reflect drawdowns for Statewide and Local Dislocated
Worker as well as Rapid Response activities. This entry must reflect the Local
Dislocated Worker portion only.
10a

Cash Receipts

The sum of the 10a entry on this report, the 10a entry on the Statewide Dislocated Worker
report (ETA-9130 (E)), and the Statewide Rapid Response report (ETA-9130 (H)) should
equal the cumulative PMS record amount posted for this subaccount.
Cash receipts reported should reflect the State’s receipt of cash to be disbursed to local
areas to pay for allowable Local Dislocated Worker costs associated with the funding
authority identified on 10d (Federal Funds Authorized).
NOTE: For grant recipients operating on a reimbursement basis, this amount should NOT
reflect cash utilized from other fund sources of the recipient organization to initially pay for
subject grant activities.
Enter the cumulative amount of cash disbursed from the cash receipts identified on 10a,
as of the reporting period end date. The cash disbursements reported must be all or a
portion of the cash receipts reflected on Item 10a.
This entry should reflect the sum of actual cash disbursements for direct charges for goods
and services, the amount of cash paid out for indirect expenses, and the amount of cash
advance payments and payments made to subrecipients and subcontractors.

10b

Cash Disbursements
NOTE: Line 10e (Federal Share of Expenditures) will typically be greater than Line 10b due
to the inclusion of accruals, for which payment has not been made. If allowable advances
made to subrecipients, cause Line 10b to exceed Line 10e, a valid explanation should be
provided in Section 12, Remarks.
If the cumulative entry for this line item is less than the previous period cumulative amount, a
valid explanation should be provided in Section 12, Remarks.
This is an automatic calculation, which is Line 10a (Cash Receipts) minus Line 10b (Cash
Disbursements).

10c

Cash on Hand
(line 10a minus line 10b)

The cash on hand amount should represent immediate cash needs. An explanation for the
excess cash on hand amount should be provided in Section 12, Remarks.
NOTE: In accordance with Department of Treasury regulations, federal cash must be
drawn solely to accommodate immediate needs.

Federal Expenditures and Unobligated Balance:
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Financial Report Instructions
Line Item
Number

Reporting/Line Item

ETA-9130 (F) – Local Dislocated Worker
Instructions
Enter the total amount of Dislocated Worker (DW) funds (from the State DW funding stream
allotment) allocated to the local areas for allowable local DW activities.

10d

Total Federal Funds Authorized

NOTE: After the first 2 years of a Program Year of funding, any local DW funds recaptured
by the State and returned for statewide activities should be reflected by a decrease in this
entry. A corresponding increase will be made to Line 10d of the Statewide DW report (ETA9130 (E)). Local DW funds recaptured from one local area and allocated to another local
area will precipitate no change to this line item.
Enter the cumulative amount of accrued expenditures for allowable costs associated with
the funds authorized on Line10d (Total Federal Funds Authorized).
DOL/ETA requires reporting on an accrual basis. If the recipient’s accounting system is not
on an accrual basis, the recipient will not be required to convert its accounting system, but
must develop and report such accrual information through best estimates based on an
analysis of the documentation on hand (2 CFR 2900.14).

10e

Federal Share of Expenditures

Expenditures for reports prepared on an accrual basis are the sum of: actual cash
disbursements specified in Line 10b for direct charges for goods and services; the amount of
indirect expenses incurred; net increase or decrease in the amounts owed by the nonFederal entity for goods and property received; and services performed by employees,
contractors, subrecipients, and other payees, and programs for which no current services or
performance are required such as annuities, insurance claims, or other benefit payments,
minus any rebates, refunds, or other credits.
Unless cash advances have been made to subrecipients or there is a reduction for rebates,
refunds, or other credits, this entry will usually be greater than Line 10b (Cash
Disbursements) because accruals (goods and services received but not yet paid for) must
be included on this line item. Non-Federal entities must liquidate existing cash advances
before requesting additional advances (2 CFR 2900.7). In addition, recipients operating on a
reimbursement basis must report all accrued expenditures (including cash disbursements for
allowable grant activities) in the quarter in which they occur.
NOTE: If the cumulative entry for this line item is less than the previous period cumulative
amount, a valid explanation should be provided in Section 12, Remarks.
During the closeout process, funds not expended during the grant period will be deobligated. Exception: Funds obligated for pay-for-performance contracts (WIOA Sec. 189
(g)(2)(D)).
Enter the cumulative amount of accrued expenditures charged to the DW local area grants
for administrative activities. This line item is a portion of the amount reported on Line
10e (Federal Share of Expenditures).

10f

Total Administrative Expenditures

NOTE: Because 10% of the total Youth, Adult, and Dislocated Worker funds available for
expenditure at the local areas may be expended on administration (without regard to funding
source), the funds identified on this line item, do not need to be allocable to the local DW
program, but may be allocable to local Youth and Adult activities, as well.
According to WIOA Sec. 3 (1), “[t]he term ‘‘administrative costs’’ means expenditures
incurred […] in the performance of administrative functions and in carrying out activities
under title I that are not related to the direct provision of workforce investment services
(including services to participants and employers). Such costs include both personnel and
nonpersonnel costs and both direct and indirect costs.”
Enter any obligations incurred, for which an accrued expenditure has not yet been recorded,
as of the reporting period end date.

10g

Federal Share of Unliquidated
Obligations

Unliquidated obligations should include amounts which will become due to subrecipients and
contractors. On the final report, this line item should be zero.
The OMB Uniform Guidance defines “Obligation” in 2 CFR 200.71 as follows: “When used
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Financial Report Instructions
Line Item
Number

ETA-9130 (F) – Local Dislocated Worker

Reporting/Line Item

Instructions
in connection with a non-Federal entity’s utilization of funds under a Federal award,
obligations means orders placed for property and services, contracts and subawards made,
and similar transactions during a given period that require payment by the non-Federal entity
during the same or a future period.” Please refer to 2 CFR 200 and 2 CFR 2900 for
additional guidance.
NOTE: For DOL/ETA grants, the only liquidation that can occur during closeout is the
liquidation of accrued expenditures (NOT obligations) for goods and/or services received
during the grant period.
Do not include any amount on Line 10g that has been reported on Line 10e (Federal Share
of Expenditures) or 10f (Total Administrative Expenditures). Do not include any amount on
Line 10g for a future commitment of funds/encumbrances (e.g., entire lease, budgeted
salary costs) for which an obligation has not yet been incurred.

10h

Total Federal Obligations
(sum of lines 10e and 10g)

Local funds obligated for Pay-for-Performance contracts remain available until expended.
See WIOA Sec. 189 (g)(2)(D).
This is an automatic calculation, which is the sum of Lines 10e (Federal Share of
Expenditures) and 10g (Federal Share of Unliquidated Obligations).

10i

Unobligated Balance of Federal Funds
(line 10d minus line 10i)

This is an automatic calculation, which is Line 10d (Total Federal Funds Authorized) minus
Line Item 10h (Total Federal Obligations).

Recipient Share:
Enter the total match requirement, if applicable. A match requirement will be listed in the
grant award document and on the SF-424a, Section A, Column F “Non-Federal.”
If there is no match requirement, a ZERO must be entered.

This line item must include the amount of non-federal share employers are
required to provide based on incumbent worker training (IWT) contracts.
10j

Total Recipient Share Required

NOTE: Per WIOA Sec. 134 (d)(4)(C), employers participating in a local area incumbent
worker training (IWT) program shall be required to pay for the non-Federal share of the
cost of providing the training to incumbent workers of the employers. WIOA Sec. 134
(d)(4)(D)(ii) specifies that such contributions shall not be less than:
 10 percent of the cost, for employers with not more than 50 employees;
 25 percent of the cost, for employers with more than 50 employees but not
more than 100 employees; and
 50 percent of the cost, for employers with more than 100 employees.
Enter any non-Federal funds expended, by recipient organization, for the purposes or
activities of subject grant.
This line item must include employers’ share of expenditures, as applicable to the IWT
employer match requirement in line 10j.
Additionally, expenditures identified on this line item must:

10k

Recipient Share of Expenditures





Be allowable costs which could otherwise have been paid for out of subject grant
funds;
Include both match and other non-Federal leveraged resources; and
Include allowable non-Federal in-kind match contributions.

This entry may (and often will) exceed the required match entered on Line 10j (Total
Recipient Share Required).
NOTE: Non-Federal funds expended for the purposes or activities of the subject grant,
which are allowable under the OMB Uniform Guidance (2 CFR 200 and 2 CFR 2900), but
which are not completely allowable under the subject grant (due to a program specific
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Financial Report Instructions
Line Item
Number

10l

ETA-9130 (F) – Local Dislocated Worker

Reporting/Line Item

Remaining Recipient Share to Be
Provided
(line 10j minus line10k)

Instructions
restriction), should not be reported on this line item, but should be included in the quarterly
progress report. Other federal funds expended for the purpose and benefit of this grant
should be included in line item 11a (Other Federal Funds Expended).
This is an automatic calculation, which is Line 10j (Total Recipient Share Required) minus
Line 10k (Recipient Share of Expenditures). When the match requirement identified on
Line 10j has been met, or if Line 10j is zero, the value on Line 10l will automatically be
set to zero.

Program Income:
Enter the total amount of program income earned as the result of allowable grant activity.
The addition method for recording and reporting program income is typically required for all
ETA programs/grants. For additional reference, program income is defined in the applicable
program regulations and in 2 CFR 200.80 and 2 CFR 200.307.
10m

Total Program Income Earned

Either gross or net program income may be reported. If gross program income is reported,
the costs for generating the income should be included on Line 10e (Federal Share of
Expenditures). If net program income is reported, the costs for generating the income are
subtracted from the total income earned before entering the net amount on 10m.
If no program income is earned, a ZERO must be entered.
Enter the cumulative amount of accrued expenditures incurred against the program income
earned on Line 10m (Total Program Income Earned).

10n

Program Income Expended in
Accordance with the Addition Method

10o

Unexpended Program Income
(line 10n minus line 10o)

11

Additional Obligation and Expenditure Data Required

NOTE: Program income is to be expended during the same grant period in which it is
earned and must be disbursed before requesting new cash advance payments (2 CFR
200.305 (b)(5)).
This is an automatic calculation, which is Line10m (Total Program Income Earned) minus
10n (Program Income Expended in Accordance with the Addition Method).

Enter any other Federal funds expended, by the recipient organization and any subrecipient
organizations for the same purposes or activities of the subject grant. Expenditures
included must be allowable costs which could otherwise have been paid for out of
subject grant funds.
11a

11b

Other Federal Funds Expended

Real Property Proceeds Expended

Other Federal funds expended by any non-subrecipient partner organizations for the benefit
of this grant program should be included in the quarterly progress report.
This entry should include expenditures of all Federally funded leveraged resources, whether
or not such expenditures are the result of a leveraging requirement.
Enter expenditure of funds resulting from the sale of real property purchased with DOL/ETA
ES or UI funds. Further guidance on this requirement can be found in Training and
Employment Guidance Letter No. 3-07, Transfer of Federal Equity in State Real Property to
the States, dated August 1, 2007.
NOTE: This amount should not be included in the amount reported on Line 10e (Federal
Share of Expenditures).
Enter the amount of Dislocated Worker funds expended on the Adult program.

11c

Expenditure of Dislocated Worker
funds on the Adult Program

This amount should represent the aggregate amount of Dislocated Worker funds expended
on the Adult program for local areas and it is a portion of the amount reported in 10e
(Federal Share of Expenditures).
Per WIOA Sec. 133 (b)(4), a local board may transfer, if such a transfer is approved by
the Governor, up to and including 100 percent of Dislocated Worker funds to the Adult
program and vice versa.
NOTE: Line 10d (Total Federal Funds Authorized), DOES NOT CHANGE. The funding
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Financial Report Instructions
Line Item
Number

Reporting/Line Item

11d

Federal Share of Unliquidated
Obligations for Pay-for-Performance
Contracts

11e

Pay-for-Performance Contract
Expenditures

11f

11g

Transitional Jobs Expenditures

Incumbent Worker Training
Expenditures

ETA-9130 (F) – Local Dislocated Worker
Instructions
source paying for the DW funds expended on the Adult program remains the Dislocated
Worker fund source. It is the expenditure of Dislocated Worker funds on the Adult program
that becomes allowable within the approved transfer authority.
Enter any obligations incurred for pay-for-performance contracts for which an expenditure
has not yet been recorded, as of the reporting period end date. This amount should
represent the aggregate unliquidated obligations for pay-for-performance contracts for local
areas and it is a portion of the amount reported in 10g (Federal Share of Unliquidated
Obligations).
Enter the cumulative amount of expenditures charged to the Local Dislocated Worker grants
for pay-for-performance contract costs. This line item should represent the total accrued
pay-for-performance contract expenditures for all local areas and it is a portion of the
amount reported in 10e (Federal Share of Expenditures).
WIOA Sec. 134 (d)(1)(A)(iii) sets a pay-for-performance contract expenditure cap of ten
percent of the amount of Federal funds allocated to local areas to carry out the Dislocated
Worker program for a program year.
Enter the cumulative amount of expenditures charged to the Local Dislocated Worker grants
for transitional jobs costs. This line item should represent the total accrued transitional jobs
contract expenditures for all local areas and it is a portion of the amount reported in 10e
(Federal Share of Expenditures).
WIOA Sec. 134 (d)(5) sets a transitional jobs expenditure cap of ten percent of the amount
of Federal funds allocated to local areas to carry out the Dislocated Worker program for a
program year.
Enter the cumulative amount of expenditures charged to the Local Dislocated Worker grants
for incumbent worker training costs. This line item should represent the total accrued
incumbent worker training contract expenditures for all local areas and it is a portion of the
amount reported in 10e (Federal Share of Expenditures).
WIOA Sec. 134 (d)(4)(A)(i) sets an incumbent worker training expenditure cap of twenty
percent of the amount of Federal funds allocated to local areas to carry out the Dislocated
Worker program for a program year.

Remarks
12

Enter any explanations deemed necessary by the recipient or information required by DOL/ETA. (This section supports transactions
entered on lines identified in Sections 10 and 11.)
Certification
The authorized official certifies accuracy of reported data by entering assigned PIN.

13a-b

13c
13d
13e
14

“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).”
The telephone number of the certifying official is automatically displayed. If the information
Telephone (Area Code, Number and
contained in this field is outdated or incorrect, please contact your Federal Project Officer
Extension)
(FPO) and Grant Officer to inform him/her of the error and the need to request a change.
The email address of the certifying individual is automatically displayed. If the information
Email Address
contained in this field is outdated or incorrect, please contact your Federal Project Officer
(FPO) and Grant Officer to inform him/her of the error and the need to request a change.
Date Report Submitted
The date the ETA-9130 is certified/submitted to DOL/ETA is automatically displayed.
(MM/DD/YYYY)
Agency Use Only

This section is reserved for DOL/ETA use.

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