OSM-49 Budget Information and Financial Reporting Form

U.S. DEPARTMENT OF THE INTERIOR

OMB Approval No.: 1029-0059
Exp. Date: 7/31/2021

OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT
Budget Information and Financial Reporting Form
SECTION A. GENERAL

Grantee:

Grant Title:

Grant Number:

Grant Period:  to 

SECTION B. BUDGET AND FINANCIAL REPORT INFORMATION
Budget/Cost Categories

Budget

Financial Status Report

Financial Status Report

Cumulative Through 
Title

Number

Cumulative Through

Cumulative Through

Original/

Current

Cumulative

Cumulative

Rpt

Cumulative

Cumulative

Rpt

Cumulative

Cumulative

Rpt

Prior Budget

Budget

Obligations

Expenditures

Ind

Obligations

Expenditures

Ind

Obligations

Expenditures

Ind

0.00

Total Net Program Obligations/Expenditures

0.00

Total Grant Amount

Financial Status Report

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Total Unobligated Balance

0.00

T otal Indirect Costs
Total Program Income
SECTION C. INDIRECT COST RATE INFORMATION

Type rate #1: Predetermined[ ] Final[ ] Provisional[ ] Fixed[ ] Type rate #2: Predetermined[ ]
Indirect Rate Calc: Base $_________ Indirect Amount $_______
Rate ______%

Final[ ]

Provisional[ ]

Fixed[ ]Type rate #3: Predetermined[ ] Final[ ] Provisional[ ] Fixed[ ]

Indirect Rate Calc: Base $_________ Indirect Amount $_______

Period Covered by Rate:  Rate ______%

Period Covered by Rate: 

Indirect Rate Calc: Base $_________ Indirect Amount $_______
Rate ______%

Period Covered by Rate:

SECTION D. SIGNATURES

Name/Title and Signature of Authorized Official (Grant Application) Date of Signature

Excel

Signature of Authorized Official and

Signature of Authorized Official and

Signature of Authorized Official and

Date First Annual Report Signed

Date Second Annual Report Signed

Date Third Annual Report Signed
OSM-49 (August 1995)

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501) requires us to inform you that: Federal Agencies may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. This information is
being collected to review, administer and evaluate the States/Tribes grants for program development and administration and enforcement to meet the requirements of the Surface Mining Control Reclamation and Enforcement Act. The obligation to respond is required to obtain a benefit.
Public reporting burden for this form is estimated to average 3 hours per response, including time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to the
Information Collection Clearance Officer, Office of Surface Mining Reclamation and Enforcement, 1849 C Street, NW, Room 4559, Washington, DC 20240.