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+ Do not complete when filing final report or in annual reports for individual projects which will not be refunded.

CERTIFICATION The undersigned certifies that this report has been completed in accordance with applicable instructions; that it is true to the best of his/her knowledge, information and belief; and that it has been approved, or

reviewed and approved, as indicated in Item 6, below. 8. THIS REPORT HAS BEEN (Check appropriate box.)

TE OF

PROVAL APPROVED BY GRANTET'S

O REVIEWED OY GRAN TEE'S ADMINISTERING BOARD GOVERNING BOARD

AND APPROVED IY ITS GOVERNING OFFICIALS

1. TYPED NAME . TITLE OF PRINCIPAL GOVERNING OFFICIAL

OR PRINCIPAL OFFICER OF GOVERNING BOARD

. SIGNATURE

10. DATE

CSA FORM 440 (REV. AUG 77) (REPLACES OEO FORM 440, DATED AUO 12, WHICH IS OOSOL ETE.)

OPO 1.-407

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APPENDIX F 1. FEDERAL AGENCY AND ORGANIZATIONAL ELEMENT TO WHICH REPORT IS SUBMITTED 2. FEDERAL GRANT OR OTHER IDENTIFYING OMB Approved PAGE OF

NUMBER

No. 80-RO180

PAGES - EMPLOVER IDENTIFICATION NUMBER 3. RECIPIENT ACCOUNT NUMBER OR IDENTIFYING NUMBER FINAL REPORT

7. BASIS

CJ YES NO [ CASH | ACCRUAL
PROJECT/GRANT PERIOD (Ser instructions)

9.

PERIOD COVERED BY THIS REPORT
FROM (Month day. yeer)
TO (Month, day. wer)
FROM (Month. daw. wer)

TO (Monil, dr. wer)

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DATE REPORT
SUBMITTED

m. Unobligated balance of Federal funds 2. TYPE OF RATE

13. CERTIFICATION

SIGNATURE OF AUTHORIZED CERTIFYING
11.
(Place "X" in appropricte box) PROVISIONAL PREDETERMINED FINAL FIXED

I certity to the best of my knowledge and be- OFFICIAL
INDIRECT
EXPENSE b. RATE

c. BASE
d. TOTAL AMOUNT .. FEDCML SHARE

lief that this report is correct and complete and that all outlays and unliquidated obligations

are for the purposes set forth in the award TYPED OR PRINTED NAME AND TITLE POPTning lapislation. 12. REMARKS: Attachew explanations deemed scenery or information required by Federal sponsoring pency in compliance with documents.

TELEPHONE (Area code,
number and extension)

INSTRUCTIONS

Please type or print legibly. Items 1. 2:3, 6, 7, 9, 10d, 10e, 108, 101, 101, 11a, and 12 are self-explanatory, specific instructions for other items are as follows:

Item

Entry

Item

Entry

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Enter the amount of all program income realized in this period that is required by the terms and con. ditions of the Federal award to be deducted from total project costs. For reports prepared on a cash basis, enter the amount of cash income received during the reporting period. For reports prepared on an accrual basis, enter the amount of income earned since the beginning of the reporting period. When the terms or conditions allow program income to be added to the total award, explain in remarks, the source, amount and disposition of the income.

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Enter amount pertaining to the non-Federal share of program outlays included in the amount on line e.

10

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The purpose of vertical columns (a) through (f) is to provide financial data for each program, function, and activity in the budget as approved by the Federal spon. soring agency. If additional columns te needed, use as many additional forms as needed and indicate page number in space provided in upper right; however, the totals of all programs, functions or activities should be shown in column (8) of the first page. For agreements pertaining to several Catalog of Federal Domestic Assistance programs that do not require a further functional or activity classification breakdown, enter under columns (a) through in the title of the program. For grants or other assistance agreements containing multiple programs where one or more programs require a further breakdown by function or activity, use a separate form for each program showing the applicable functions or activities in the separate columns. For grants or other assistance agreements containing several functions or activities which are funded from several programs, prepare a separate form for each activity or function when requested by the Federal sponsoring agency.

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10b

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Enter the total gross program outlays (less rebates, refunds, and other discounts) for this report period, including disbursements of cash realized as program income. For reports that are prepared on a cash basis, outlays are the sum of actual cash disburse. ments 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 contractors and subgrantees. For reports prepared on an accrued expenditure basis, outlays are the sum of actual cash disbursements, 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 and for services performed by employees, contractors, subgrantses, and other payees.

Enter amount of the Federal share charged during the report period.

If more than one rate was applied during the project period, include a separate schedule showing bases against which the indirect cost rates were applied, the respective indirect rates the month, day, and year the indirect rates were in effect, amounts of indirect ex pense charged to the project, and the Federal share of indirect expense charged to the project to date.

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15

TYPED OR PRINTED NAME AND TITLE

CERTIFICATION

SIGNATURE

DATE REPORT SUBMITTED

AUTHORIZED

! certity to the best of my knowledge and belief that this report is true in all respects and that all disburse. ments have been made for the purpose and conditions of the grant or agreement

CERTIFYING

TELEPHONE Area Core, romler, Estension)

OFFICIAL

THIS SPACE FOR AGENCY USE

272-102

STANDARD FORM 272 (7-76)
Prescribed by Omice of Management and Budget
Cir. No. A-110

INSTRUCTIONS

Please type or print legibly. Items 1, 2. 8. 9. 10. 11d, lle. 1lh, and 15 are self explanatory. specific instructions for other items are as follows:

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110-240-45) 22

STANDARD FORM 272 (BACK) (7-76)

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