Form ETA 191 ETA 191 ETA 191 - STATEMENT OF EXPENDITURES & FINANCIAL ADJS OF

UI REPORT HANDBOOK NO.401
ETA 191 – Statement of Expenditures and Financial Adjustments of Federal Funds for Unemployment Compensation for Federal
Employees and Ex-Servicemember

ETA 191 – Statement of Expenditures and Financial Adjustments of Federal Funds for Unemployment
Compensation for Federal Employees and Ex-Servicemember
SECTION II-1
A.

Facsimile of Form

STATE:

REGION:

REPORT FOR PERIOD ENDING:

SECTION A: SUMMARY STATEMENT OF EXPENDITURES AND ADJUSTMENTS
UCFE
1.

Benefit Expenditures

2.

Adjustments Assigned to Agencies:

UCX

(a) Cancellations
(b) Restoration of Overpayments
(c) Other - Explain in Comments
3.

Total Assigned Expenditures
and Adjustments
(Items 1 and 2; these totals must match
the totals reported in Section B.)

4.

Expenditures and Adjustments
Not Assigned to Agencies:
(a) Penalties and Interest
(b) Other - Explain in Comments

5.

Total Expenditures and Adjustments
Not Assigned to Agencies
(Items 4a and 4b)

6.

Grand Total - All Expenditures
and Adjustments
(Items 3 and 5)

SECTION B: DETAILED STATEMENT OF EXPENDITURES AND ADJUSTMENTS BY FEDERAL
(CIVILIAN) AND MILITARY AGENCIES
Agency
Code

(1)

Expenditures and Adjustments

Agency
Title
(2)

UCFE

UCX

(3)

(4)

Comments:
OMB No.: 1205-0162
OMB Expiration Date: 06/30/2019
OMB Burden Hours: 360 Minutes
O M B Burden Statement: These reporting instructions have been approved under the Paperwork reduction Act of
1995. Persons are not required to respond to this collection of information unless it displays a valid OMB control
Section II-1-69
7/2017