BLS OSHS TCF Transmittal and Certification Form

BUREAU OF LABOR STATISTICS

U.S. DEPARTMENT OF LABOR
TRANSMITTAL AND CERTIFICATION FORM

FOR OSHS COOPERATIVE AGREEMENT CLOSEOUT DOCUMENTS
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State Grant
Agency (SGA):
Check, or write in, the appropriate boxes:
SOII

CFOI

Other

CA Period
From:

CA#:

To:

The following documents are being submitted for the closeout of the cooperative agreement indicated above.
(Check the appropriate boxes.)
Partial
Closeout

Final
Closeout

Document Name
OSHS Financial Reconciliation Worksheet (2
Parts)
SF-425 Federal Financial Report [Item 10 (lines d – k) and
item 11 (lines a – f)]
BLS-OSHS2 Quarterly Financial Report
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."

SGA Representative:
(type/print)

Title:

Authorized Signature:

Date:
FOR THE BLS USE ONLY

Date Received in RO:

Received by:

Date Received in OFO:

Received by:

Date Received in DFM:

Received by:

Approved by (Analyst, BGFM):

Remarks:

BLS OSHS TCF (Revised June 2021)

Date: