sf 425 federal financial report (fillable).pdf

Page of pages

4b. EIN

From: To:

a. Type b. Rate c. Period

From

Period To d. Base

g. Totals:

b. Signature of Authorized Certifying Official

14. Agency use only:

e. Date Report Submitted (Month, Day, Year)

Standard Form 425 - Revised 10/11/2011

OMB Approval Number: 0348-0061

Expiration Date: 2/28/2015

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

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 intent set forth in the award documents. I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)

c. Telephone (Area code, number, and extension)a. Typed or Printed Name and Title of Authorized Certifying Official

m. Program income expended in accordance with the deduction alternative

f. Federal Share

n. Program income expended in accordance with the addition alternative

o. Unexpended program income (line l minus line m or line n)

11.

Indirect

Expense

e. Amount Charged

Program Income:

l. Total Federal share of program income earned

Recipient Share:

i. Total recipient share required

j. Recipient share of expenditures

k. Remaining recipient share to be provided (line i minus j)

g. Total Federal share (sum of lines e and f)

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

d. Total Federal funds authorized

8. Project/Grant Period (Month, Day, Year)

c. Cash on Hand (line a minus b)

(Use lines d-o for single grant reporting)

Federal Cash (To report multiple grants separately, also use FFR Attachment):

a. Cash Receipts

(Use lines a-c for single or combined multiple grant reporting)

FEDERAL FINANCIAL REPORT

(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)

Paperwork Burden Statement

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB control number for this information collection is 0348-0061. Public reporting burden for this collection of information is estimated to average 1.5 hours 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. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0061), Washington, DC 20503.

3. Recipient Organization (Name and complete address including Zip code)

4a. DUNS Number

10. Transactions Cumulative

7. Basis of Accounting6. Report Type5. Recipient Account Number or Identifying

Number (To report multiple grants, use FFR

Attachment)

9. Reporting Period End Date (Month, Day, Year)

d. Email Address

e. Federal share of expenditures

f. Federal share of unliquidated obligations

b. Cash Disbursements

Federal Expenditures and Unobligated Balance:

Quarterly

Semi-Annual

Annual

Final

Cash

Accrual