Attachment I.

SF-269A Example (LVER) FI NAN CIAL STATUS REPORT

(Short Form)
(Follow instructions on the back)
1. Federal Agency and Organizational Element 2. Federal Grant or Other Identifying Number Assigned OMB Approval
to Which Report is Submitted By Federal Agency No. Page of
0348-0038
U.S. Department of Labor (Fill-in)
Veterans' Employment and Training Service
(USDOL/VETS)
CFDA number
for Grant:
17.8
pages
3. Recipient Organization (Name and complete address, including ZIP code)
(Fill-in) Name:
(Fill-in) Address, Line 1:
(Fill-in) Address, Line 2:
(Required (Fill-in)
(Fill-in) City: Fill-in) Zip Code:
State:

5. Recipient Account Number or Identifying Number

(Fill-in) State Grant Number's Fiscal Year Identifier Digit. Also fill-in
4. Employer Identification Number last two digits of Grant Number (if "#N/A" is shown). 6. Final Report 7. Basis
Y N Ca Accr
E-9-5- -50 #N/A
es o sh ual
8. Funding/Grant Period (See instructions) 9. Period Covered by this Report
From: (Month, Day, Year) To: (Month, Day, Year) From: (Month, Day, Year) To: (Month, Day, Year)
(Fill-in)
Fiscal Year:
10. Transactions: I II III
Previously This Cumulative
Reported Period

a. Total outlays 0

b. Recipient share of outlays 0

c. Federal share of outlays 0

d. Total unliquidated obligations

e. Recipient share of unliquidated obligations

f. Federal share of unliquidated obligations

g. Total Federal share (sum of lines c and f) 0

h. Total Federal funds authorized for this funding period

i. Unobligated balance of Federal funds (Line h minus line g) 0

a. Type of Rate (Place "X" in appropriate box) F
Predetermine Fixe
Provisional ina
11. Indirect d d
Expense b. Rate c. Base d. Total Amount l e. Federal Share

12. Remarks: Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation.

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 are for the purposes set forth in the award documents.
Typed or Printed Name and Title Telephone (Area code, number and extension)

(Fill-in) Name:
(Fill-in) Title:
Signature of Authorized Certifying Official Date Report Submitted

NSN 7540-01-218-4387 269-202 Standard Form 269A (Rev. 7-97)

Prescribed by OMB Circulars A-102 and A-110