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FINANCIAL STATUS REPORT <br /> (Short Form) <br /> (Follow instructions on the back) <br /> 1. Federal Agency and Organizational Element 2. Federal Grant or Other Identifying Number Assigned OMB Approval Page of <br /> to Which Report is Submitted By Federa! Agency No. <br /> 0348-0038 <br /> pages <br /> 3. Recipient Organization (Name and complete address, including ZIP code) <br /> 4. Employer Identification Number. 5. Recipient Account Number or Identifying Number 6. Final Report 7. Basis <br /> ? Yes ? No ? Cash Accrual <br /> 8. Funding/Grant Period (See instructions) 9. Period Covered by this Report <br /> From: (Month, Day, Year) To: (Month, Day, Year) From: (Month, Day, Year) To: (Month, Day, Year) <br /> 10. Transactions: I 1{ III <br /> Previously This Cumulative <br /> Reported Period <br /> a. Total outlays <br /> b. Recipient share of outlays <br /> c. Federal share of outlays <br /> _ <br /> d. Total unliquidated obligations <br /> e. Recipient share of unliquidated obligations <br /> f. Federal share of unliquidated obligations <br /> g. Total Federal share(Sum of lines c and f) <br /> h. Total Federal funds authorized for this funding period <br /> i. Unobligated balance of Federal fund~'Line h. minus line g) <br /> a. Type of Rate(P/ace 'X" in appropriate box) <br /> 11. Indirect ? Provisional ? Predetermined ? Final ? Fixed <br /> Expense b. Hate c. base d. Tatai Amount e. Federal Share <br /> 12. Remarks: Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing <br /> legislation. <br /> 13. Certification: I certify to the best of my knowledge and belief that this report is correct and complete and that all outlays and <br /> unliquidated obligations are for the purposes set forth in the award documents. <br /> Typed or Printed Name and Title Telephone (Area code, number and extension) <br /> Signature of Authorized Certifying Official Date Report Submitted <br /> <br /> NSN 7540-01-218-4387 269-202 Standard Form 269A (Rev. 7-97) <br /> Prescribed by OMB Circulars A-102 and A-11( <br /> <br />