SF-269 Financial Status Report - Long

FINANCIAL STATUS REPORT
(Long Form)
(Follow instructions of 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
No.
0348-0039

Page of

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

4. Employer Identification Number

5. Recipient Account Number or Identifying Number

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

To: (Month, Day Year)

10. Transactions:

6. Final Report
† Yes † No
9. Period Covered by this Report
From: (Month, Day, Year)

I
Previously Reported

7. Basis
† Cash

† Accrual

To: (Month, Day Year)

II
This Period

III
Cumulative

a. Total outlays
b. Refunds, rebates, etc.
c. Program income used in accordance with the deduction alternative
d. Net outlays (Line a, less the sum of lines b and c)
Recipient’s share of net outlays, consisting of:
e. Third party (in-kind) contributions
f. Other Federal awards authorized to be used to match this award
g. Program income used in accordance with the matching or cost sharing alternative
h. All other recipient outlays not shown on lines e, f or g
i. Total recipient share of net outlays (Sum of lines e, f, g and h)
j. Federal share of net outlays (line d less line i)
k. Total unliquidated obligations
l. Recipient’s share of unliquidated obligations
m. Federal share of unliquidated obligations
n. Total Federal share (sum of lines j and m)
o. Total Federal funds authorized for this funding period
p. Unobligated balance of Federal funds (Line o minus line n)
Program Income, consisting of:
q. Disbursed program income shown on lines c and/or g above
r. Disbursed program income using the addition alternative
s. Undisbursed program income
t. Total program income realized (Sum of lines q, r and s)
a. Type of Rate (Place “X” in appropriate box)
† Provisional
†Predetermined
11. Indirect
Expense

b. Rate

†Final

c. Base

† Fixed
d. Total Amount

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.

Type or Printed Name and Title

Telephone (Area code, number and extension)

Signature of Authorized Certifying Official

Date Report Submitted

Previous Edition Usable
7-2009)

269-104

Standard Form 269 (Rev.
Prescribed by OMB Circulars A-102 and

A-110
NSN 7540-01-012-4285

200-498 P.O. 139 (Face)

FINANCIAL STATUS REPORT
(Long Form)
The public reporting and recordkeeping burden for this collection of information is estimated to average 30 minutes per response. Send comments on the Agency's
need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of
automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.
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 (e.g., how to calculate the Federal share, the permissible uses of program income, the value of in-kind contributions, etc.) You may
also contact the Federal agency directly.
Item

Entry

1, 2 and 3.

Self-explanatory.

4.

Enter the Employer Identification Number (EIN) 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.

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”.

9.

Self-explanatory.

Item

Entry

10b.

Enter any receipts related to outlays reported on the
form that are being treated as a reduction of
expenditure rather than income, and were not already
netted out of the amount shown as outlays on line
10a.

10c

Enter the amount of program income that was used in
accordance with the deduction alternative.

Note:

Program income used in accordance with other
alternatives is entered on lines q, r, and s. Recipients
reporting on a cash basis should enter the amount of
cash income received; on an accrual basis, enter the
program income earned. Program income may or
may not have been included in an application budget
and/or a budget on the award document. If actual
income is from a different source or is significantly
different in amount, attach an explanation or use the
remarks section.
e, f, g, h, i and j. Self-explanatory.

10.

10a.

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 and column I entry on this report and attach an
explanation.

10d.
10k.

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.

Enter total gross program outlays. Include disbursements of cash realized as
program income if that income with also be shown on line 10c or 10g. Do not
include program income that will be shown on lines 10r or 10s.
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 subrecipients. 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 indirect expense incurred, the value of inkind contributions applied, and the net increase or decrease in the amounts
owned by the recipient for goods and other property received, for services
performed by employees, contractors, subgrantees and other payees, and other
amounts becoming owned under programs for which no current services or
performances are required, such as annuities, insurance claims, and other benefit
payments.

Enter the total amount of unliquidated obligations,
including unliquidated obligations to subgrantee and
contractors.

Do not include any amounts on line 10k that have
been included on lines 10a and 10j.
On the final report, line 10k must be zero.
Self-explanatory.
10l.
On the final report, line 10m must also be zero.
10m.
o, p, q, r, s and t. Self-explanatory.
10n.
Self-explanatory.
11a.
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.
Enter the Federal share of the amount in 11d.

11e.
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.
SF-269 Back (Rev. 7-2009)