ETA-9130K Senior Community Service Employment Program

Senior Community Service Employment Program

U.S. DOL ETA FINANCIAL REPORT
(Follow instructions on the back.)
1. Federal Agency and Organizational Element to Which Report is Submitted

OMB Approval No. 1205-0461

2. Federal Grant or Other Identifying Number Assigned by DOL

Expires 10/31/2022
3. Recipient Organization (Name and complete address including Zip code)
4a. Unique Entity Identifier

4b. EIN

5. Recipient Account Number or Identifying Number

6. Final Report

Yes
8. Project/Grant Period From: (MM/DD/YYYY)

To: (MM/DD/YYYY)

7. Basis of Reporting

No

Accrual

9. Reporting Period End Date (MM/DD/YYYY)

10. Transactions
Federal Cash:
a. Cash Receipts
b. Cash Disbursements
c. Cash on Hand (line a minus b)

Cumulative

$

-

Federal Expenditures and Unobligated Balance:
d. Total Federal Funds Authorized
e. Federal Share of Expenditures
f. Total Administrative Expenditures
g. Federal Share of Unliquidated Obligations
h. Total Federal Obligations (sum of lines e and g)
i. Unobligated Balance of Federal Funds (line d minus h)

$
$

-

Recipient Share:
j. Total Recipient Share Required
k. Recipient Share of Expenditures
l. Remaining Recipient Share to Be Provided (line j minus k)

$

-

Program Income:
m. Total Program Income Earned
n. Program Income Expended in Accordance with the Addition Method
o. Unexpended Program Income (line m minus line n)

$

-

11. Additional Expenditure Data Required
a. Other Federal Funds Expended
b. Administration - Headquarters
c. Administration - Local
d. Enrollee Wages and Fringe Benefits
e. Other Enrollee Expenditures
12. Remarks: (Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation.)

13. Indirect Expenditures
a. Type of Rate

b. Rate

c. Rate Approval Date

d. Period From
(MM/DD/YYYY)

Period To
(MM/DD/YYYY)

e. Base

f. Amount Charged

g. Federal Share

h. Totals: $
$
$
14. 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. Typed or Printed Name and Title of Authorized Certifying Official

c. Telephone (Area code, number, and extension)
d. Email Address

b. Signature of Authorized Certifying Official

e. Date Report Submitted (MM/DD/YYYY)
15. Agency Use Only:
Prescribed by OMB Uniform Guidance 2 CFR 200.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB number. Public reporting burden for this collection of information, which is required to obtain or retain
benefits (2 CFR 200.327 and WIOA Section 185(e)(2)), is estimated to average 45 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. The reason for the collection of information is general program oversight, evaluation and performance assessment. Send comments
regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to ETA Office of Management and Administrative Services, Rm N-4653, U.S.
Department of Labor, Washington DC 20210.
ETA-9130 (K)