Form IA 7703A IA 7703A Version 1 - Tribal Temporary Assistance for Needy Famili

IA Form 7703A NOTE: IA Form 7703A will be obsolete starting Month, Date, 2017

OMB Control No. 1076-0135 (Version 1)

Exp. Date: mm/dd/yyyy

Tribal Temporary Assistance for Needy Families (TANF) ACF – 102-477 Financial Report 12g
TRIBE NAME	FISCAL YEAR			FISCAL YEAR ENDING DATE	Employer ID Number (EIN)
GRANT DOCUMENT NUMBER (BIA)
REPORTING ITEMS	(A) FEDERAL TFAG FUNDS			(B) TRIBAL FUNDS [OPTIONAL]*	(C) STATE CONTRIBUTED MOE FUNDS [OPTIONAL]
1. TOTAL AWARDED	$			$	$
2. CASH ASSISTANCE	$			$	$
3. OTHER ASSISTANCE EXPENDITURES	$			$	$
4. TOTAL NON-ASSISTANCE EXPENDITURES	$			$	$
5. ADMINISTRATION	$			$	$
6. SYSTEMS	$			$	$
7. OTHER EXPENDITURES	$			$	$
8. TRIBAL REPLACEMENT FUNDS				$
9. FEDERAL UNLIQUIDATED OBLIGATIONS	$
THIS IS TO CERTIFY THAT THE INFORMATION REPORTED ON ALL PARTS OF THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE
SIGNATURE: AUTHORIZED TRIBAL OFFICIAL		SUBMITTAL: [ ] NEW [ ] REVISED	TYPED NAME, TITLE, AGENCY NAME
DATE SUMITTED:
*Tribe must fill in Column (B) if it is subject to a penalty and corresponding reduction in its Tribal Family Assistance Grant (TFAG).
Data for lines 10 to 12 will be completed by the Federal Awarding Agency
REPORTING ITEMS	(A) FEDERAL TFAG FUNDS			(B) TRIBAL FUNDS [OPTIONAL]*	(C) STATE CONTRIBUTED MOE FUNDS [OPTIONAL]
10. TOTAL EXPENDITURES ON ASSISTANCE	$			$	$
11. TOTAL EXPENDITURES	$			$	$
12. FEDERAL UNOBLIGATED BALANCES	$

	Optional
	No Response Necessary

Paperwork Reduction Act Statement: The information being collected meets the requirements of Public Law 102-477 for program evaluation, compliance, audit and program planning and management purposes. The data collected is shared with all participating Federal agencies providing funds. The reports are used to monitor the progress of the grantees in delivering services to tribal members, to identify unmet needs, to identify any other problems, and to provide information to justify budget submissions by the three federal agencies involved. Only tribes who have voluntarily applied to participate in this project will submit the annual report. Response is required to obtain benefits of the program. This report takes about 2 hours to complete. An agency may not request or sponsor a collection of information, and a person is not required to respond to a request, if a valid OMB control number is not provided. Comments concerning this information collection can be sent to: Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, Mail Stop 3071, Washington, DC 20240. Please note: comments, names and addresses of commenters are available for public review during regular business hours. If you wish us to withhold this information, you must state that prominently at the beginning of your comment. We will honor your request to the extent allowable by law.