FNS 683 Current Instrument

OMB APPROVED NO. 0584-0594
Expiration Date: 06/30/2017

U.S. DEPARTMENT OF AGRICULTURE - Food and Nutrition Service

WIC FARMERS' MARKET NUTRITION PROGRAM (FMNP)
ANNUAL FINANCIAL AND PROGRAM DATA REPORT
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 0584-0594. The time equired to complete this information collection is estimated to
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information collection.

PART A - HEADING
1. FEDERAL AGENCY AND ORGANIZATIONAL ELEMENT TO
WHICH REPORT IS SUBMITTED
FOOD AND NUTRITION SERVICE, USDA

2. STATE 7-DIGIT AGENCY CODE

3. UNIVERSAL IDENTIFIER NUMBER

4. STATE AGENCY NAME AND ADDRESS

5. BASIS
CASH

6. REPORT YEAR
Revision 0, Closeout Report
From
To

ACCRUAL

PART B - ANALYSIS OF REPORT YEAR PROGRAM ACTIVITY
FOOD (A)

COST CATEGORY
ADMIN. (B)

TOTAL (C)

TRANSACTION
7. FORMULA GRANT
8. BACKSPEND TO PRIOR YEAR
9. SUBTOTAL (7 PLUS 8)
10. GROSS OUTLAYS AND UNLIQUIDATED OBLIGATIONS FOR REPORT YEAR
11. PROGRAM INCOME
12. NET OUTLAYS AND UNLIQUIDATED OBLIGATIONS (10 MINUS 11)
13. RECIPIENT'S SHARE OF NET OUTLAYS AND UNLIQUIDATED OBLIGATIONS
14. FEDERAL PROGRAM OUTLAYS AND UNLIQUIDATED OBLIGATIONS (12 MINUS
13)
15. BALANCE (9 MINUS 14)
16. BACKSPEND FROM FOLLOWING YEAR
17. RESULTS OF REPORT YEAR PROGRAM OPERATIONS (15 PLUS 16)

PART C - STATUS OF GRANT AWARD
18. FEDERAL OUTLAYS AGAINST THE FORMULA GRANT:
a. FOR REPORT YEAR OUTLAYS
b. FOR OUTLAYS OF PRIOR YEAR (BACKSPENT)
c. TOTAL FEDERAL OUTLAYS (18a PLUS 18b)
19. FEDERAL UNLIQUIDATED OBLIGATIONS AGAINST THE FORMULA GRANT
20. FEDERAL OUTLAYS AND UNLIQUIDATED OBLIGATIONS (18c PLUS 19)
21. FEDERAL FUNDS TO BE RECOVERED (7 MINUS 20)
a. TYPE OF RATE (check appropriate box)
Provisional
Predetermined
22. INDIRECT
EXPENSE

b. RATE

c. BASE

Final

Fixed
d. TOTAL AMOUNT

e. FEDERAL SHARE

PART D - PROGRAM DATA
WIC RECIPIENTS SUPPORTED WITH FEDERAL AND NON-FEDERAL
NON-WIC RECIPIENTS SUPPORTED BY NON-FEDERAL FUNDS
FUNDS
23. PREGNANT WOMEN

30. CHILDREN
31. ELDERLY
32. OTHER
33. TOTAL NON-WIC RECIPIENTS
34. TOTAL OF WIC AND NON-WIC RECIPIENT (LINE
28 PLUS LINE 33)

24. BREASTFEEDING WOMEN
25. POSTPARTUM WOMEN
26. INFANTS
27. CHILDREN
28. TOTAL WIC RECIPIENTS (Line 23 THRU Line 27)
29. HOUSEHOLDS
Form FNS-683 (01/14) Previous Editions are Obsolete

SBU
Electronic Form Version Designed in Adobe 10 Version

PROFILE OF VENDORS

FMNP ISSUANCE AND REDEMPTION SUMMARY

35. NUMBER OF AUTHORIZED FARMERS
36. NUMBER OF AUTHORIZED FARMERS' MARKETS
37. NUMBER OF AUTHORIZED FARM OR ROADSIDE
STANDS, IF ANY
38. NUMBER OF COUPONS ISSUED (FEDERAL)
39. NUMBER OF COUPONS ISSUED (NON-FEDERAL)

40. TOTAL VALUE OF COUPONS ISSUED (FEDERAL +
NON-FEDERAL)
41. NUMBER OF COUPONS REDEEMED (FEDERAL)
42. NUMBER OF COUPONS REDEEMED (NONFEDERAL)
43. TOTAL VALUE OF COUPONS REDEEMED
(FEDERAL + NON- FEDERAL)

35. NUMBER OF AUTHORIZED FARMERS
36. NUMBER OF AUTHORIZED FARMERS' MARKETS
37. NUMBER OF AUTHORIZED FARM OR ROADSIDE
STANDS, IF ANY
38. NUMBER OF COUPONS ISSUED (FEDERAL)
39. NUMBER OF COUPONS ISSUED (NON-FEDERAL)

40. TOTAL VALUE OF COUPONS ISSUED (FEDERAL +
NON-FEDERAL)
41. NUMBER OF COUPONS REDEEMED (FEDERAL)
42. NUMBER OF COUPONS REDEEMED (NONFEDERAL)
43. TOTAL VALUE OF COUPONS REDEEMED
(FEDERAL + NON- FEDERAL)

PART E - OTHER
REMARKS

CERTIFICATION:
TYPED NAME AND TITLE OF CERTIFYING OFFICIAL
I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT THIS REPORT IS
CORRECT AND THAT ALL OUTLAYS AND UNLIQUIDATED OBLIGATIONS ARE FOR SIGNATURE
THE PURPOSES SET FORTH IN THE AWARD DOCUMENT.
TELEPHONE NUMBER

DATE