Form FNS-667 Report of the Emergency Food Assistance Program (TEFAP)

FORM APPROVED OMB NO. 0584-0385
(Expiration Date 4/30/03)
UNITED STATES DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION SERVICE

REPORT OF THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) ADMINISTRATIVE COSTS
According to the Paperwork Reduction Act of 1995, 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 0584-0385. The average time required to complete
this collection is estimated to be 3.5 hours per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection.
1. ID NUMBER

2. STATE AGENCY

3. FINAL REPORT
NO

YES
4. BASIS
CASH

5. GRANT PERIOD
FROM (Month, Day, Year)

TO (Month, Day, Year)

ACCRUAL

6. PERIOD COVERED BY THIS REPORT
FROM (Month, Day, Year)

TO (Month, Day, Year)

7. STATUS OF FUNDS
ACTIVITIES/FUNCTIONS
TRANSACTIONS

I - STATE LEVEL
COSTS

II - STATE PAID
EFO COSTS

III - LOCAL-PAID
EFO COSTS

IV - TOTAL COST

a. Net Outlays Previously Reported
b. Net Outlays This Quarter
c. Net Outlays to Date (Sum of lines a and b)
STATE AGENCY'S SHARE OF NET OUTLAYS,
CONSISTING OF:
d. Third-Party In-Kind Contributions
e. Cash Outlays
f. Total State Agency's Share of Net Outlays
(Sum of lines d and e)
g. Federal Share of Net Outlays (Line c minus line f)
h. Total Unliquidated Obligations
i. State Agency's Share of Unliquidated Obligations
j. Federal Share of Unliquidated Obligations
(Line h minus line i)
k. Total Federal share (Sum of lines g and j)
l. Total Federal Funds Authorized
m. Unobligated Balance of Federal Funds
(Line l minus line k)

8. CERTIFICATION: I certify to the best of my knowledge and belief that this report is correct and complete
and that all outlays and unliquidated obligations are for the purposes set forth in the awards documents.
NAME AND TITLE (Typed or Printed)

TELEPHONE NUMBER

SIGNATURE

DATE (Report Submitted)

FORM FNS-667 (01-03)

Electronic Form Version, Designed in JetForm 5.1 Version

INSTRUCTIONS
FNS-667
PURPOSE

Line f and g are self-explanatory.

The FNS-667 captures the State agency's outlays and
unliquidated obligations for TEFAP storage and distribution
costs in total and at the State and local levels. This information is necessary to monitor the State agency's use of its
TEFAP grant. It is also needed in order to determine compliance
wit certain programmatic requirements. These include the State
matching requirement (7CFR 25.19) and the 40 percent passthrough requirement (7 CFR 251.8(d)(2)(h).

Line h - Total Unliquidated Obligations. Enter the State Agency's
balance of unliquidated obligations for State level storage and
distribution costs, from both Federal and State sources as of the
report date.

LINE-BY-LINE INSTRUCTIONS
Block 1 - ID Number. Enter the 7-digit identification (ID) number
assigned by FNS. This number identifies the State agency and
its TEFAP grant in the FNS automated reporting system.

Line i - State Agency's Share of Unliquidated Obligations. Enter
the portion of the line h entry that does not represent obligations
of Federal grant funds for State level storage and distribution
costs.
Lines j and k are self-explanatory.

Block 2 - State Agency. Enter the name and address of the
State Agency.

Line l - Federal Funds Authorized. Enter the portion of the Federal
grant (as stated in block 8 of the most recent Grant Award Document) that will be used for State level costs. This amount should
not exceed 60 percent of the Federal grant shown in column IV of
the final report, although it may do so in quarterly interim reports.

Block 3 - Final Report. If this is the final report submitted to
close out the grant, check "yes". Otherwise, check "no".

Line m - Unobligated Balance of Federal Funds. Subtract the line
k entry from the l entry and enter the result here.

Block 4 - Basis. Check the block corresponding to the basis
of accounting cash or accrual under which the State Agency
prepared the data entered in the report.

Column II - State-Paid EFO Costs.

Block 5 - Grant Period. Enter the beginning and ending dates
of the Federal fiscal year for which the grant has been awarded.
Block 6 - Period Covered by this Report. Enter the beginning
and ending dates of the calendar quarter to which this report
pertains.
Block 7 - Status of Funds:
Column 1 - State Level Costs.
This column isl used to report transactions relating to TEFAP
State level storage and distribution costs. The State Agency
identifies such costs in accordance with section IV of FNS
Instruction 716-3, Temporary Emergency Feed Assistance
Program (TEFAP) -- Storage and Distribution Costs.
Line a - Net Outlays Previously Reported. Enter the cumulative
net outlays from all sources (Federal grant, State appropriated
funds, third-party in-kind contributions, etc.) for State level
costs as of the close of the quarter preceding the quarter
identified in block 6. This amount should be the same as the
line c entry in the last report. If this is the initial report, enter
zero.
Line b - Net Outlays This Quarter. Enter the net outlays for
State level costs for the quarter to which this report pertains
(as shown in block 6).
Line c - Net Outlays to Date. Enter the sum of lines a and b.
This is the total cumulative outlay for State level costs as of
the report date.

General. This column is used to report transactions relating to
EFO level storage and distribution costs which have been paid
directly by the State Agency. The State Agency identifies such
costs in accordance with section V of FNS Instruction 716-3.
The line-by-line instructions for this column parallel those given
above for column l.
Line I - Total Federal Funds Authorized. The State Agency must
distribute the portion of its grant (as shown on the Grant Award
Document) that will be passed through to EFOs between columns
II and III on a basis that reflects the State Agency's expectation
of how actual expenditures for EFO level costs will be distributed.
Column III - Local Paid EFO Costs.
This column is used to report Federal grant funds disbursed to
EFOs for costs incurred by the EFOs themselves. The State
Agency identifies such costs in accordance with section VI of
FNS Instruction 716-3. The State Agency should follow the
Column I line-by-line instructions in completing lines a through
k and line m of Column III. The Column II instruction for completing line l should also be applied to line l of Column III.
Column IV - Total.
General. Sum the values entered in Column I through III of each
line and enter the total for each line in the applicable cell of
column IV.
Line I - Total Federal Funds Authorized. The entry in this row
should match the amount shown in section 8, Federal Grant
Obligation, of the Grant Award Document.
Timing and Submission.

Line d - Third Party In-Kind Contributions. Enter the value of
goods and services furnished by donors other than the State,
which qualify to be counted toward meeting the matching
requirement (See 7 CFR 251.8(c)).

The FNS-667 is due in the applicable FNS regional office 30 days
following the end of the calendar quarter to which it pertains. The
final (closeout) report is due January 30 of the Federal fiscal year
following that to which the final report pertains.

Line e - Cash Outlays. Enter all cash outlays by the State
Agency for State level storage and distribution costs, from
sources either than the Federal grant, which qualify to be
counted toward meeting the matching requirements. (See
7 CFR 251.8 (c)).

NOTE: If TEFAP funds are used for administrative costs of the
Soup Kitchens & Food Banks Program, the reporting State Agency
must ensure that the numbers shown on the FNS-667 reflect such
usage.