State, Local, Tribal Government Reporting

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

EPA Form: 560F22292
OMB Control No. 2050-0192
Expiration Date: XX-XX-XXXX

REVOLVING LOAN FUND (RLF) Program Income Form —Brownfields
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2050-0192). Responses to this collection of information are mandatory (2 CFR
200.328, 2 CFR 200.333, 2 CFR 200.335, 40 CFR 30-31). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 0.75 hours per response. Send comments on the Agency’s need for this information, the
accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

1. Cooperative Agreement Recipient Name:

2. Cooperative Agreement Number:

PROGRAM INCOME (PI) BALANCE INFORMATION (for Open and Closed RLF grants)
3. Program Income Balance:
4. As of this Date:
5. Is additional Program Income expected?

Yes

No

POST-CLOSEOUT PROGRAM INCOME BALANCE INFORMATION (for Post-Closeout RLF grants)
6. Total Post-Closeout Program Income (PCPI) Balance:
7. As of this Date:
6a. Committed PCPI Balance:
6b. Uncommitted PCPI Balance:
8. PCPI Earned in last 12 months:
9. PCPI Expended in last 12 months:
10. Is additional PCPI expected?

Yes

No

CLOSEOUT AGREEMENT (for Closed or Post-Closeout RLF grants)
11. Does this Cooperative Agreement have a Closeout Agreement?
Yes
(If yes, answer questions 12-16)

No

12. Closeout Agreement Start Date:
13. Is this Closeout Agreement linked to any other RLF Cooperative
Agreements?

Yes

No

Yes

No

14. If yes, indicate the RLF Cooperative Agreement number(s):
15. Is this Closeout Agreement still active?
16. If no, indicate Closeout Agreement End Date:
POST-CLOSEOUT REPORT (for Closed or Post-Closeout RLF grants)
17. Submission Date for most recent Post-Closeout Report:
18. Is a Post-Closeout Report still required?

Yes

No