Form Standard Form 269 Standard Form 269 Financial Status Report (Long Form)

FINANCIAL STATUS REPORT
(Long 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 of
No.

0348-0039

pages

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

4. Employer Identification Number

5. Recipient Account Number or Identifying Number

6. Final Report
Yes

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

To: (Month, Day, Year)

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

10. Transactions:
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)

7. Basis
Cash

No

Accrual

To: (Month, Day, Year)

I

I

III

Previously Reported

This Period

Cumulative

0.00
0.00

0.00

0.00

0.00

0.00

Recipient's share of net outlays, consisting of:
e. Third party (in-kind) contributions
f.

0.00

Other Federal awards authorized to be used to match this award

0.00

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)

0.00
0.00
0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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.

11. Indirect
Expense
12.

b.

0.00

Type of Rate (Place "X" in appropriate box)
Provisional
Rate

c.

Predetermined

Base

d.

Total Amount

Final

Fixed
e.

Federal Share

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

April 16, 2001
Previous Edition Usable

269-104

NSN 7540-01-012-4285

Standard Form 269 (Rev. 7-97)
Prescribed by OMB Circulars A-102 and A-110

200-498 P.O. 139 (Face)

FINANCIAL STATUS REPORT
(Long Form)
Public reporting burden for this collection of information is estimated to average 30 minutes 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 (0348-0039), Washington, DC 20503.

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

Item

Entry

4. Enter the Employer Identification Number (EIN)
assigned by the U.S. Internal Revenue Service.

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.

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

10c. Enter the amount of program income that was used in
accordance with the deduction alternative.

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

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.

1, 2 and 3. Self-explanatory.

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.
10. 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 gross program outlays. Include
disbursements of cash realized as program income
if that income will also be shown on lines 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 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.

10d,

e, f, g, h, i and j. Self-explanatory.

10k. Enter the total 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 10k that have been
included on lines 10a and 10j.
On the final report, line 10k must be zero.
10l. Self-explanatory.
10m. On the final report, line 10m must also be zero.
10n,

o, p, q, r, s and t. 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.

SF-269 Back (Rev. 7-97)