Form SF-269A Financial Status Report

FINANCIAL STATUS REPORT
(Short Form)
(Follow instructions on the back)
1. Federal Agency and Organizational Element
to Which Report is Submitted

2. Federal Grant or Other Identifying Number
Assigned By Federal Agency

OMB Approval Page
No.

of

0348-0039
pages

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

4. Employer Identification Number

8. Funding/Grant Period (See Instructions)
From: (Month, Day, Year)

5. Recipient Account Number or Identifying Number

To: (Month, Day, Year)

9. Period Covered by this Report
From: (Month, Day, Year)

10. Transactions

I
Previously
Reported

a.

Total outlays

b.

Recipient share of outlays

c.

Federal share of outlays

d.

Total unliquidated obligations

e.

Recipient share of unliquidated obligations

f.

Federal share of unliquidated obligations

g.

Total Federal share (Sum of lines c and f)

h.

Total Federal funds authorized for this funding period

i.

Unobligated balance of Federal funds (Line h minus line g)

11. Indirect
Expense

6. Final Report
Yes

a. Type of Rate (Place “X” in appropriate box)
Provisional
b. Rate

c. Base

No

7. Basis
Cash

To: (Month, Day, Year)

II
This
Period

Predetermined

Final

d. Total Amount

Accrual

III
Cumulative

Fixed
e. Federal Share

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

13. 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 award documents.

Typed or Printed Name and Title

Telephone (Area code, number and extension)

Signature of Authorized Certifying Official

Date Report Submitted

Standard Form 269A (REV 4-88)
Prescribed by OMB Circulars A-102 and A-110

FINANCIAL STATUS REPORT
(Short Form)

Please type or print legibly. The following general instructions explain how to use the form itself. You may need
additional information to complete certain items correctly, or to decide whether a specific item is applicable to
this award. Usually, such information will be found in the Federal agency's grant regulations or in the terms and
conditions of the award. You may also contact the Federal agency directly.
Item
Entry
Item
Entry
1, 2 and 3.

Self-explanatory.

indirect expense incurred, the value of in-kind
contributions applied, and the net increase or
decrease in the amounts owed by the recipient
for goods and other property received, for
services performed by employees, contractors,
subgrantees and other payees, and other amounts
becoming owed under programs for which no
current services or performances are required,
such as annuities, insurance claims, and other
benefit payments.

4.

Enter the employer identification number
assigned by the U.S. Internal Revenue
Service.

5.

Space reserved for an account number or other
identifying number assigned by the recipient.

6.

Check yes only if this is the last report for the
period shown in item 8.

7.

Self-explanatory.

10b. Self-explanatory.

8.

Unless you have received other instructions
from the awarding agency, enter the
beginning and ending dates of the current
funding period. If this is a multi-year
program, the Federal agency might require
cumulative reporting through consecutive
funding periods. In that case, enter the
beginning and ending dates of the grant
period, and in the rest of these instructions,
substitute the term “grant period” for
“funding period.”

10c. Self-explanatory.

9.
10.

Self-explanatory.
The purpose of columns, I, II and III is to show
the effect of this reporting period's transactions
on cumulative financial status. The amounts
entered in column I will normally be the same
as those in column III of the previous report in
the same funding period. If this is the first or
only report of the funding period, leave
columns I and II blank. If you need to adjust
amounts entered on previous reports, footnote
the column I entry on this report and attach an
explanation.

10a. Enter total program outlays less any rebates,
refunds, or other credits. For reports prepared
on a cash basis, outlays are the sum of actual
cash disbursements for direct costs for goods
and services, the amount of indirect expense
charged, the value of in-kind contributions
applied, and the amount of cash advances and
payments made to sub-recipients. For reports
prepared on an accrual basis, outlays are the
sum of actual cash disbursements for direct
charges for goods and services, the amount of

10d. Enter the amount of unliquidated obligations,
including unliquidated obligations to subgrantees
and contractors.
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 outlay has not yet been recorded.
Do not include any amounts on line 10d that have
been included on lines 10a, b or c.
On the final report, line 10d must be zero.
10e, f, g, h and i. Self-explanatory.
11a. Self-explanatory.
11b. Enter the indirect cost rate in effect during the
reporting period.
11c. Enter the amount of the base against which the
rate was applied.
11d. Enter the total amount of indirect costs charged
during the report period.
11e. Enter the Federal share of the amount in 11d.
Note: If more than one rate was in effect during the
period shown in item 8, attach a schedule
showing the bases against which the different
rates were applied, the respective rates, the
calendar periods they were in effect, amounts of
indirect expense charged to the project, and the
Federal share of indirect expense charged to the
project to date.

Standard Form 269A (REV 4-88)
Prescribed by OMB Circulars A-102 and A-110