BLS LMI TCF Transmittal and Certification Form

BUREAU OF LABOR STATISTICS

U.S. DEPARTMENT OF LABOR

TRANSMITTAL AND CERTIFICATION FORM
FOR LMI COOPERATIVE AGREEMENT CLOSEOUT DOCUMENTS
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Approval Expires
05-31-2021

State Workforce
Agency (SWA):
CA#:

CA Period From:

To:

The following documents are being submitted for the closeout of the cooperative agreement indicated above.
(Check the appropriate boxes under the column heading of either Partial Closeout or Final Closeout.)
Partial
Closeout

Final
Closeout

Document Name
LMI Financial Reconciliation Worksheet (2 Parts)
Financial Reports
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."
SWA Representative:
(type/print)
Authorized Signature:

Title:
Date:

FOR THE BLS USE ONLY
Date Received in RO:

Received by:

Date Received in OFO:

Received by:

Date Received in DFPM:

Received by:

Approved by (Analyst, BGFM):
Remarks:

BLS LMI TCF (Revised May 2018)

Date: