BLS LMI TCF Transmittal and Certification Form

BUREAU OF LABOR STATISTICS

U.S. DEPARTMENT OF LABOR
TRANSMITTAL AND CERTIFICATION FORM

FOR LMI COOPERATIVE AGREEMENT CLOSEOUT DOCUMENTS

We estimate that it will take an average of 8 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 49L-1. 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
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OMB No. 1220-0079
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State Workforce
Agency (SWA):
CA#:

CA Period From:

To:

The following documents are being submitted for the closeout of the cooperative agreement indicated above.
(Check the appropriate boxes under the column heading of either Partial Closeout or Final Closeout.)
Partial
Closeout

Final
Closeout

Document Name
LMI Financial Reconciliation Worksheet (2 Parts)
Financial Reports
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."
SWA
Representative:
(type/print)
Authorized
Signature:

Title:
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 LMI TCF (Revised May 2018)

Date: