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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. 6. THIS REPORT HAS BEEN (Check appropriate box.)

DATE OF

APPROVAL O APPROVED BY GRANTEE'S

REVIEWED BY GRAN TEE'S ADMINISTERING BOARD GOVERNING BOARD

AND APPROVED BY ITS GOVERNING OFFICIALS

9. SIGNATURE

10. DATE

8. TYPED NAME & TITLE OF PRINCIPAL GOVERNING OFFICIAL

OR PRINCIPAL OFFICER OF GOVERNING BOARD

CSA FORM 440 (REV. AUG 77) (REPLACES OEO FORM 440, DATED AUG 72, WHICH IS OBSOLETE)

GPO 91 9-407

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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
4. EMPLOYER IDENTIFICATION NUMBER
5. RECIPIENT ACCOUNT NUMBER OR IDENTIFYING NUMBER 6. FINAL REPORT

7. BASIS
(YES UNO

CASH () ACCRUAL
PROJECT/GRANT PERIOD (Ser instructions)

PERIOD COVERED BY THIS REPORT
FROM (Month, day. year)
TO (Month, day, wear)
FROM (Month. dan wear)

TO (Month, day, wear)

INSTRUCTIONS

Please type or print legibly. Items 1, 2; 3, 6, 7, 9, 10d, 10e, 10g, 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.

Enter the month, day, and year of the beginning and ending of this project period. For formula grants that are not awarded on a project basis, show the grant period.

100 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 are 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 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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10a Enter the net outlay. This amount should be the same

as the amount reported in Line 10e of the last report. If there has been an adjustment to the amount shown previously, please attach explanation. Show zero if this is the initial report.

Enter the unobligated balance of Federal funds. This amount should be the difference between lines k and I.

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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, subgrantees, 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

ne 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.

APPENDIX G

FEDERAL CASH TRANSACTIONS REPORT 1. Federal

Approved by Orice of Management and Budget, No. 80-RO182 11. Federal sponsoring ocong and organizational alement to which this report

is submitted (See instructions on the back. If report is for more than one grant or assistance agreement, attach completed Standard Form 272-4.) 2. RECIPIENT ORGANIZATION

4. Federal grant or other identifica 5. Recipient's account number of tion number

identifying number

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.

12. THE AMOUNT SHOWN 13.

OTHER INFORMATION
ON LINE 11J, ABOVE,
REPRESENTS CASH RE

a. Interest income
QUIREMENTS FOR THE
ENSUING

Days

b. Advances to subgrantees or subcontractors 14. REMARKS (Attach additional sheets of plain paper, if more space is required)

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272-102

272-102

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

INSTRUCTIONS

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

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