SF425_2_0-V2.0 Federal Financial Report.pdf

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RR_SF424 Page 1 mhughes D:20061211100100- 05'00' D:20061211100100- 05'00'

1. Federal Agency and Organizational Element to Which Report is Submitted 4a. DUNS Number Recipient Organization Name:

Street1:

Street2:

City:

State:

ZIP / Postal Code:

Country:

Quarterly Federal Financial Report (Follow form Instructions) County:

Province:

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) 4b. EIN

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

6. Report Type Semi-Annual Annual Final

7. Basis of Accounting Accrual Cash

8. Project/Grant Period To:

From:

9. Reporting Period End Date

a. Cash Receipts

c. Cash on Hand (line a minus b)

b. Cash Disbursements

10. Transactions Cumulative (Use lines a-c for single or multiple grant reporting) Federal Cash (To report multiple grants, also use FFR attachment):

(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)

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

i. Total recipient share required

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

j. Recipient share of expenditures Program Income:

l. Total Federal program income earned

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

m. Program Income expended in accordance with the deduction alternative

n. Program Income expended in accordance with the addition alternative OMB Number: 4040-0014 Expiration Date: 02/28/2022

b. Signature of Authorized Certifying Official

e. Date Report Submitted

First Name:

Middle Name:

Last Name:

Suffix:

Title:

c. Telephone (Area code, number and extension)

d. Email Address Prefix:

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).

11. Indirect Expense

a. Type

d. Base

f. Federal Share

b. Rate

c. Period From Period To

e. Amount Charged

g. Totals:

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

a. Name and Title of Authorized Certifying Official

14. Agency use only:

Standard Form 425 Federal Financial Report Instructions Report Submissions 1) Recipients will be instructed by Federal agencies to submit the Federal Financial Report (FFR) to a single location, except when an automated payment management reporting system is utilized. In this case, a second submission location may be required by the agency.

2) If recipients need more space to support their FFRs, or FFR Attachments, they should provide supplemental pages. These additional pages must indicate the following information at the top of each page: Federal grant or other identifying number (if reporting on a single award), recipient organization, Data Universal Numbering System (DUNS) number, Employer Identification Number (EIN), and period covered by the report.

Reporting Requirements Note: For single award reporting:

1) Federal agencies may require both cash management information on lines 10(a) through 10(c) and financial status information lines 10(d) through 10(o).

2) 10(b) and 10(e) may not be the same until the final report.

Line Item Instructions for the Federal Financial Report FFR Number Reporting Item Instructions Cover Information Federal Agency and Organizational Element toWhich Report is Submitted Enter the name of the Federal agency and organizational element identified in the award document or as instructed by the agency.

Federal Grant or OtherIdentifying Number Assigned by Federal Agency For a single award, enter the grant number assigned to the award by theFederal agency. For multiple awards, report this information on the FFRAttachment. Do not complete this box if reporting on multiple awards.

Recipient Organization Enter the name and complete address of the recipient organization including zip code.

4a DUNS Number Enter the recipient organization's Data Universal Numbering System (DUNS) number or Central Contract Registry extended DUNS number.

4b

EIN

Enter the recipient organization's Employer Identification Number (EIN).

Recipient Account Number or Identifying Number Enter the account number or any other identifying number assigned by the recipient to the award. This number is for the recipient's use only and is not required by the Federal agency. For multiple awards, report this Revised 6/28/2010 The submission of interim FFRs will be on a quarterly, semi-annual, or annual basis, as directed by the Federal agency. A final FFR shall be submitted at the completion of the award agreement. The following reporting period end dates shall be used for interim reports: 3/31, 6/30, 9/30, or 12/31. For final FFRs, the reporting period end date shall be the end date of the project or grant period.

1) Quarterly and semi-annual interim reports shall be submitted no later than 30 days after the end of each reporting period. Annual reports shall be submitted no later than 90 days after the end of each reporting period. Final reports shall be submitted no later than 90 days after the project or grant period end date.

2) information on the FFR Attachment. Do not complete this box ifreporting on multiple awards.

Report Type Mark appropriate box. Do not complete this box if reporting on multipleawards.

Basis of Accounting (Cash/Accrual) Specify whether a cash or accrual basis was used for recordingtransactions related to the award(s) and for preparing this FFR. Accrualbasis of accounting refers to the accounting method in which expenses arerecorded when incurred. For cash basis accounting, expenses are recorded when they are paid.

Project/Grant Period, From: (Month, Day, Year) Indicate the period established in the award document during which Federal sponsorship begins and ends.

Note: Some agencies award multi-year grants for a project period that is funded in increments or budget periods (typically annual increments).

Throughout the project period, agencies often require cumulative reporting for consecutive budget periods. Under these circumstances, enter the beginning and ending dates of the project period not the budget period.

Do not complete this line if reporting on multiple awards.

Project/Grant Period, To:(Month, Day, Year) See the above instructions for "Project/Grant Period, From: (Month, Day,Year)."

Reporting Period End Date: (Month, Day, Year) Enter the ending date of the reporting period. For quarterly, semi-annual,and annual interim reports, use the following reporting period end dates:3/31, 6/30, 9/30, or 12/31. For final FFRs, the reporting period end dateshall be the end date of the project or grant period.

Transactions Enter cumulative amounts from date of the inception of the award through the end date of the reporting period specified in line 9.

Use Lines 10a through 10c, Lines 10d through 10o, or Lines 10a through 10o, as specified by the Federal agency, when reporting on single grants.

Use Line 12, Remarks, to provide any information deemed necessary to support or explain FFR data.

Federal Cash (To report multiple grants, also use FFR Attachment) 10a Cash Receipts Enter the cumulative amount of actual cash received from the Federal agency as of the reporting period end date.

10b Cash Disbursements Enter the cumulative amount of Federal fund disbursements (such as cashor checks) as of the reporting period end date. Disbursements are the sum of actual cash disbursements for direct charges for goods and services, the amount of indirect expenses charged to the award, and the amount of cash advances and payments made to subrecipients and contractors.

For multiple grants, report each grant separately on the FFR Attachment.The sum of the cumulative cash disbursements on the FFR Attachment must equal the amount entered on Line 10b, FFR.

10c Cash On Hand (Line 10a Minus Line 10b) Enter the amount of Line 10a minus Line 10b. This amount represents immediate cash needs. If more than three business days of cash are on hand, the Federal agency may require an explanation Revised 6/28/2010 Instructions Reporting Item FFR Number FFR Number Reporting Item Instructions on Line 12, Remarks, explaining why the drawdown was made prematurely or other reasons for the excess cash.

Federal Expenditures and Unobligated Balance: Do not complete this section if reporting on multipleawards.

10d Total Federal Funds Authorized Enter the total Federal funds authorized as of the reporting period end date.

10e Federal Share of Expenditures Enter the amount of Federal fund expenditures. For reports prepared on a cash basis, expenditures are the sum of cash disbursements for direct charges for property and services; the amount of indirect expense charged; and the amount of cash advance payments and payments made to subrecipients. For reports prepared on an accrual basis, expenditures are the sum of cash disbursements for direct charges for property and services; the amount of indirect expense incurred; and the net increase or decrease in the amounts owed by the recipient for (1) goods and other property received; (2) services performed by employees, contractors, subrecipients, and other payees; and (3) programs for which no current services or performance are required. Do not include program income expended in accordance with the deduction alternative, rebates, refunds, or other credits. (Program income expended in accordance with the deduction alternative should be reported separately on Line 10o.)

10f Federal Share of Unliquidated Obligations Unliquidated obligations on a cash basis are obligations incurred, but not yet paid. On an accrual basis, they are obligations incurred, but for which an expenditure has not yet been recorded. Enter the Federal portion of unliquidated obligations. Those obligations include direct and indirect expenses incurred but not yet paid or charged to the award, including amounts due to subrecipients and contractors. On the final report, this line should be zero unless the awarding agency has provided other instructions.

Do not include any amount in Line 10f that has been reported in Line 10e.

Do not include any amount in Line 10f for a future commitment of funds (such as a long-term contract) for which an obligation or expense has not been incurred.

10g Total Federal Share (Sum of Lines 10e and 10f) Enter the sum of Lines 10e and 10f.

10h Unobligated Balance of Federal Funds (Line 10d Minus Line 10g) Enter the amount of Line 10d minus Line 10g.

Recipient Share: Do not complete this section if reporting on multiple awards.

10i Total Recipient Share Required Enter the total required recipient share for reporting period specified in line 9. The required recipient share should include all matching and cost sharing provided by recipients and third-party providers to meet the level required by the Federal agency. This amount should not include cost sharing and match amounts in excess of the amount required by the Federal agency (for example, cost overruns for which the recipient incurs additional expenses and, therefore, contributes a greater level of cost Revised 6/28/2010 FFR Number Reporting Item Instructions sharing or match than the level required by the Federal agency).

10j Recipient Share of Expenditures Enter the recipient share of actual cash disbursements or outlays (less any rebates, refunds, or other credits) including payments to subrecipients and contractors. This amount may include the value of allowable third party in-kind contributions and recipient share of program income used to finance the non-Federal share of the project or program. Note: On the final report this line should be equal to or greater than the amount of Line 10i.

10k Remaining Recipient Share to be Provided (Line 10i Minus Line 10j) Enter the amount of Line 10i minus Line 10j. If recipient share in Line 10j is greater than the required match amount in Line 10i, enter zero.

Program Income: Do not complete this section if reporting on multiple awards.

10l Total Federal Program Income Earned Enter the amount of Federal program income earned. Do not report any program income here that is being allocated as part of the recipient's cost sharing amount included in Line10j.

10m Program Income Expended in Accordance With the Deduction Alternative Enter the amount of program income that was used to reduce the Federal share of the total project costs.

10n Program Income Expended in Accordance With the Addition Alternative Enter the amount of program income that was added to funds committed to the total project costs and expended to further eligible project or program activities.

10o Unexpended Program Income (Line 10l Minus Line 10m or Line 10n) Enter the amount of Line 10l minus Line 10m or Line 10n. This amount equals the program income that has been earned but not expended, as of the reporting period end date.

Indirect Expense: Complete this information only if required by the awarding agency. Entercumulative amounts from date of the inception of the award through the end date of the reportingperiod specified in line 9.

11a Type of Rate(s) State whether indirect cost rate(s) is Provisional, Predetermined, Final, or Fixed.

11b Rate Enter the indirect cost rate(s) in effect during the reporting period.

11c Period From; Period To Enter the beginning and ending effective dates for the rate(s).

11d Base Enter the amount of the base against which the rate(s) was applied.

11e Amount Charged Enter the amount of indirect costs charged during the time period specified. (Multiply 11b. x 11d.)

11f Federal Share Enter the Federal share of the amount in 11e.

11g Totals Enter the totals for columns 11d, 11e, and 11f.

Remarks, Certification, and Agency Use Only Remarks Enter any explanations or additional information required by the Federal sponsoring agency including excess cash as stated in line 10c.

13a Typed or Printed Name and Title of Authorized Certifying Official Enter the name and title of the authorized certifying official.

13b Signature of Authorized Certifying Official The authorized certifying official must sign here.

13c Telephone (Area Code, Number and Extension) Enter the telephone number (including area code and extension) of the individual listed in Line 13a.

13d E-mail Address Enter the e-mail address of the individual listed in Line 13a.

Revised 6/28/2010 FFR Number Reporting Item Instructions 13e Date Report Submitted (Month, Day, Year) Enter the date the FFR is submitted to the Federal agency using themonth, day, year format.

Agency Use Only This section is reserved for Federal agency use.

Revised 6/28/2010

(To report multiple grants, use FFR Attachment) This field is required.:

Quarterly: Select this option.:

Semi-Annual: Select this option.:

Report Type: Select one.

Annual: Select this option.:

Report Type: Select one.

Final: Select this option.:

Basis of Accounting: Select one.

Accrual: Select this option.:

Basis of Accounting: Select one.

Cash: Select this option.:

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 4040-0014. Public reporting burden for this collection of information is estimated to average 1 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. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: US Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave, SW, Suite 336-E, Washington DC 20201. Attention: PRA Reports Clearance Officer: