Standard Form 269

FINANCIAL STATUS REPORT

*(Long Form)*

*(Follow instructions on the back)*

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 18%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 15%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="4"><p>1. Federal Agency and Organizational Element</p>
<p>to Which Report is Submitted</p></td>
<td colspan="5"><p>2. Federal Grant or Other Identifying Number
Assigned</p>
<p>By Federal Agency</p></td>
<td colspan="3"><p>OMB Approval</p>
<p>No. 0348-0039</p></td>
<td><p>Page of</p>
<p>Pages</p></td>
</tr>
<tr class="even">
<td colspan="13">3. Recipient Organization (Name and complete address,
including ZIP code)</td>
</tr>
<tr class="odd">
<td colspan="2">4. Employer Identification Number</td>
<td colspan="5">5. Recipient Account Number or Identifying Number</td>
<td colspan="4"><p>6. Final Report</p>
<p> Yes No</p></td>
<td colspan="2"><p>7. Basis</p>
<p> Cash Accrual</p></td>
</tr>
<tr class="even">
<td colspan="2"><p>8. Funding/Grant Period <em>(See
instructions)</em></p>
<p>From: (Month, Day, Year)</p></td>
<td colspan="3">To: (Month, Day, Year)</td>
<td colspan="5"><p>9. Period Covered by this Report</p>
<p>From: (Month, Day, Year)</p></td>
<td colspan="3">To: (Month, Day, Year)</td>
</tr>
<tr class="odd">
<td colspan="5">10. Transactions:</td>
<td colspan="3"><p>I</p>
<p>Previously Reported</p></td>
<td colspan="3"><p>II</p>
<p>This Period</p></td>
<td colspan="2"><p>III</p>
<p>Cumulative</p></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>a. Total outlays</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>b. Refunds, rebates, etc.</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>c. Program income used in accordance with the deduction
alternative</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>d. Net outlays <em>(Line a, less the sum of lines b and c)</em></p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="5"><p>Recipient's share of net outlays, consisting of:</p>
<blockquote>
<p>e. Third party (in-kind) contributions</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>f. Other Federal awards authorized to be used to match this award</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>g. Program income used in accordance with the matching or cost</p>
</blockquote>
<p>sharing alternative</p></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>h. All other recipient outlays not shown on lines e, f or g</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>i. Total recipient share of net outlays <em>(Sum of lines, e, f, g
and h)</em></p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>j. Federal share of net outlays (line d less line i)</p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>k. Total unliquidated obligations</p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>l. Recipient's share of unliquidated obligations</p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>m. Federal share of unliquidated obligations</p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>n. Total federal share (sum of lines j and m)</p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>o. Total federal funds authorized for this funding period</p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>p. Unobligated balance of federal funds (<em>Line o minus line
n)</em></p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="5"><p>Program income, consisting of:</p>
<blockquote>
<p>q. Disbursed program income shown on lines c and/or g above</p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>r. Disbursed program income using the addition alternative</p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>s. Undisbursed program income</p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>t. Total program income realized (<em>Sum of lines q, r and
s)</em></p>
</blockquote></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td rowspan="2"><p>11. Indirect</p>
<p>Expense</p></td>
<td colspan="12"><p>a. Type of Rate <em>(Place "X" in appropriate
box)</em></p>
<p> Provisional Predetermined Final Fixed</p></td>
</tr>
<tr class="even">
<td colspan="2">b. Rate</td>
<td colspan="3">c. Base</td>
<td colspan="4">d. Total Amount</td>
<td colspan="3">e. Federal Share</td>
</tr>
<tr class="odd">
<td colspan="13"><p>12. <em>Remarks: Attach any explanations deemed
necessary or information required by Federal sponsoring agency in
compliance with</em></p>
<p><em>governing legislation:</em></p></td>
</tr>
<tr class="even">
<td colspan="13"><p>13. Certification: I certify to the best of my
knowledge and belief that this report is correct and complete and that
all outlays and unliquidated obligations</p>
<p>are for the purpose set forth in the award documents.</p></td>
</tr>
<tr class="odd">
<td colspan="7">Typed or Printed Name and Title</td>
<td colspan="6">Telephone (Area code, number and extension)</td>
</tr>
<tr class="even">
<td colspan="7">Signature of Authorized Certifying Official</td>
<td colspan="6">Date Report Submitted</td>
</tr>
</tbody>
</table>

Previous Edition Usable 269-104 Standard Form 269 (REV 7-97)

NSN 7540-01-012-4285 Prescribed by OMB Circulars A-102 and A-110

200-498 P.O. 139 (Face)

Standard Form 269

FINANCIAL STATUS REPORT

*(Long Form)*

+-----------------------------------------------------------------------+
| Public reporting burden for this collection of information is         |
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| and maintaining the data needed, and completing and reviewing the     |
| collection of information. Send comments regarding the burden         |
| estimate or any other aspect of this collection of information,       |
| including suggestions for reducing this burden, to the Office of      |
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| Washington, DC 20503.                                                 |
|                                                                       |
| PLEASE [DO NOT]{.underline} RETURN YOUR COMPLETED FORM TO THE OFFICE  |
| OF MANAGEMENT AND BUDGET, SEND IT TO                                  |
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Please type or print legibly. The following general instructions explain
how to use the form itself. You may need additional information to
complete certain items correctly, or to decide whether a specific item
is applicable to this award. Usually, such information will be found in
the Federal agency\'s grant regulations or in the terms and conditions
of the award (e.g., how to calculate the Federal share, the permissible
uses of program income, the value of in-kind contributions, etc.). You
may also contact the Federal agency directly.

[Item Entry Item Entry]{.underline}

1, 2 and 3. Self-explanatory.

4\. Enter the Employer Identification Number (EIN) assigned by the U.S.
Internal Revenue Service.

5\. Space reserved for an account number or other identifying number
assigned by the recipient.

6\. Check yes only if this is the last report for the period shown in
item 8.

7\. Self-explanatory.

8\. Unless you have received other instructions from the awarding
agency, enter the beginning and ending dates of the current funding
period. If this is a multi-year program, the Federal agency might
require cumulative reporting through consecutive funding periods. In
that case, enter the beginning and ending dates of the grant period, and
in the rest of these instructions, substitute the term \"grant period\"
for \"funding period.\"

9\. Self-explanatory.

10\. The purpose of columns, I, II and III is to show the effect of this
reporting period\'s transactions on cumulative financial status. The
amounts entered in column I will normally be the same as those in column
III of the previous report *in the same funding period*. If this is the
first or only report of the funding period, leave columns I and II
blank. If you need to adjust amounts entered on previous reports,
footnote the column I entry on this report and attach an explanation.

10a. Enter total gross program outlays. Include disburse-ments of cash
realized as program income in that income will also be shown on lines
10c or 10g. Do not include program income that will be shown on lines
10r or 10s.

> For reports prepared on a cash basis, outlays are the sum of actual
> cash disbursements for direct costs for goods and services, the amount
> of indirect expense charged, the value of in-kind contributions
> applied, and the amount of cash advances payments made to
> subrecipients. For reports prepared on an accrual basis, outlays are
> the sum of actual cash disbursements for direct charges for goods and
> services, 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,
> for services performed by employees, contractors, subgrantees and
> other payees, and other amounts becoming owed under programs for which
> no current services or performances are required, such as annuities,
> insurance claims, and other benefit payments.

10.b. Enter any receipts related to outlays reported on the form that
are being treated as a reduction of expenditure rather than income, and
were not already netted out of the amount shown as outlays on line 10a.

10.c Enter the amount of program income that was used in accordance with
the deduction alternative.

Note: Program income used in accordance with other alternatives is
entered on lines q, r, and s. Recipients reporting on a cash basis
should enter the amount of cash income received; on an accrual basis,
enter the program income earned. Program income may or may not have been
included in an application budget and/or a budget on the award document.
If actual income is from a different source or is significantly
different in amount, attach an explanation or use the remarks section.

10d, e, f, g, h, i, and j. Self-explanatory.

10k. Enter the total amount of unliquidated obligations, including
unliquidated obligations to subgrantees and contractors.

> Unliquidated obligations on a cash basis are obligations incurred, but
> not yet paid. On an accrual basis, they are obligations incurred, but
> for which an outlay has not yet been recorded.
>
> Do not include any amounts on line 10k that have been included on
> lines 10a and 10j.

On the final report, line 10k must be zero.

10l. Self-explanatory.

10m. On the final report, line 10m must also be zero.

10n, o, p, q, r, s and t. Self-explanatory.

11a. Self-explanatory.

11b. Enter the indirect cost rate in effect during the reporting period.

11c. Enter the amount of the base against which the rate was applied.

11d. Enter the total amount of indirect costs charged during the report
period.

11e. Enter the Federal share of the amount in 11d.

Note: If more than one rate was in effect during the period shown in
item 8, attach a schedule showing the bases against which the different
rates were applied, the respective rates, the calendar periods they were
in effect, amounts of indirect expense charged to the project, and the
Federal share of indirect expense charged to the project to date.

SF 269 BACK (Rev 7-97)