OSHS TCF Transmittal and Certification Form

BUREAU OF LABOR STATISTICS

U.S. DEPARTMENT OF LABOR

TRANSMITTAL AND CERTIFICATION FORM

FOR OSHS COOPERATIVE AGREEMENT CLOSEOUT DOCUMENTS

We estimate that it will take an average of 5-10 minutes to complete this form including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. Your response is required to obtain or retain benefits under 29 USC 673. If you have any comments regarding these estimates or any other aspect of this form, including suggestions for reducing this burden, send them to the Bureau of Labor Statistics, Division of Financial Planning and Management (1220-0149), 2 Massachusetts Avenue, NE, Room 4135, Washington, DC 20212-0001. You are not required to respond to the collection of information unless it displays a currently valid OMB control number.

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State Grant Agency (SGA):

Check, or write in, the appropriate boxes:

SOII

CFOI

Other

CA#:

CA Period From:

To:

The following documents are being submitted for the closeout of the cooperative agreement indicated above.

(Check the appropriate boxes.)

Document Name

OSHS Financial Reconciliation Worksheet

SF-425 Federal Financial Report [Item 10 (lines d – k) and item 11 (lines a – f)]

BLS-OSHS2 Quarterly Financial Report

Property Listing (if applicable)

Other (Specify)

________________

"I certify, to the best of my knowledge and belief, that all information on this form is correct and complete. Further, all information on all documents that accompany and constitute the cooperative agreement closeout package are correct and complete. Finally, I certify, to the best of my knowledge and belief, that all program objectives, as delineated in the cooperative agreement work statement(s), have been met."

SGA Representative:

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