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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. . THIS REPORT HAS BEEN (Check appropriate box.) APPROVED SY GRANTEP'S

O REVIEWED OV GRANTEE'S ADMINISTERING BOARD

7. DATE OF

APPROVAL

GOVERNING BOARD

AND APPROVED BY ITS GOVERNING OFFICIALS

1. TYPED NAME TITLE OF PRINCIPAL GOVERNING OFFICIAL

OR PRINCIPAL OPFICER OF GOVERNING DOARD

.. SIONATURE

10. DATE

CSA PORN TU (REV. AUG 17 IREPLACES OEO FORM 140, DATED AUG 12, WHICH IS OOSOLETE.)

PO .1-407

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APPENDIX F 1. FEDERAL AGENCY AND ORGANIZATIONAL ELEMENT TO WHICH REPORT IS SUOMITTED 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 FINAL REPORT

7. BASIS
(YES NO

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

PERIOD COVERED BY THIS REPORT
FROM (Month, day, rear)
TO (Monik, day, wer)
FROM (Month, dan war)

TO Month day, weer)

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INSTRUCTIONS

Please type or print legibly. Items 1, 2:3, 6, 7, 9, 100, 10e, 10g. 10i, 101, 11a, and 12 are self-explanatory, specific instructions for other items are as follows:

Item

Entry

Ilom

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 propered on a cesh 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 ate 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 (1) the title of the program. For grants or other assistance agreements containing multiplo programs where one or more programs require a further breakdown by function of 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 sev. eral 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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10. 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.

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100

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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, out. lays 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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INSTRUCTIONS

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

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