State, Local, Tribal Competitive

Federal Financial Report

View Burden Statement

OMB Number: 4040-0014
Expiration Date: 02/28/2022

(Follow form Instructions)

1. Federal Agency and Organizational Element to Which Report is Submitted

2. Federal Grant or Other Identifying Number Assigned by Federal
Agency (To report multiple grants, use FFR Attachment)

3. Recipient Organization (Name and complete address including Zip code)
Recipient Organization Name:
Street1:
Street2:
City:

County:
Province:

State:
Country:
4a. DUNS Number

6. Report Type

ZIP / Postal Code:
4b. EIN

7. Basis of Accounting

Quarterly

Cash

Semi-Annual

Accrual

5. Recipient Account Number or Identifying Number
(To report multiple grants, use FFR Attachment)

8. Project/Grant Period
From:

9. Reporting Period End Date

To:

Annual
Final
10. Transactions

Cumulative

(Use lines a-c for single or multiple grant reporting)
Federal Cash (To report multiple grants, also use FFR attachment):
a. Cash Receipts
b. Cash Disbursements
c. Cash on Hand (line a minus b)

0.00

(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d. Total Federal funds authorized
e. Federal share of expenditures
f. Federal share of unliquidated obligations
g. Total Federal share (sum of lines e and f)

0.00

h. Unobligated balance of Federal Funds (line d minus g)

0.00

Recipient Share:
i. Total recipient share required
j. Recipient share of expenditures
k. Remaining recipient share to be provided (line i minus j)
Program Income:
l. Total Federal program income earned
m. Program Income expended in accordance with the deduction alternative
n. Program Income expended in accordance with the addition alternative
o. Unexpended program income (line l minus line m or line n)

0.00

11. Indirect Expense
a. Type

b. Rate

c. Period From

Period To

g. Totals:

e. Amount

d. Base

f. Federal Share

Charged

0.00

0.00

0.00

12. Remarks: Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
Add Attachment

Delete Attachment

View Attachment

13. Certification: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the
expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I
am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or
administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730
and 3801-3812).
a. Name and Title of Authorized Certifying Official
Prefix:

First Name:

Last Name:

Middle Name:
Suffix:

Title:
b. Signature of Authorized Certifying Official

c. Telephone (Area code, number and extension)

d. Email Address

e. Date Report Submitted

14. Agency use only:

Standard Form 425