(Follow form instructions)
1. Federal Agency and Organizational Element 2. Federal Grant or Other Identifying Number Assigned by Federal Agency Page of
to Which Report is Submitted (To report multiple grants, use FFR Attachment) 1
3. Recipient Organization (Name and complete address including Zip code)
4a. DUNS Number 4b. EIN 5. Recipient Account Number or Identifying Number 6. Report Type 7. Basis of Accounting
(To report multiple grants, use FFR Attachment)
Cash Accrual
8. Project/Grant Period 9. Reporting Period End Date
From: (Month, Day, Year)
To: (Month, Day, Year) (Month, Day, Year)
10. Transactions
(Use lines a-c for single or multiple grant reporting)
Federal Cash (To report multiple grants, also use FFR Attachment):
a. Cash Receipts
b. Cash Disbursements
c. Cash on Hand (line a minus b)
(Use lines d-o for single grant reporting)
Federal Expenditures and Unobligated Balance:
d. Total Federal funds authorized
e. Federal share of expenditures
f. Federal share of unliquidated obligations
gg.. Total Federal share Total Federal share ((sumsum of lines e and f lines e and f))
h. Unobligated balance of Federal funds (line d minus g)
Recipient Share:
i. Total recipient share required
j. Recipient share of expenditures
k. Remaining recipient share to be provided (line i minus j)
Program Income:
l. Total Federal program income earned
m. Program income expended in accordance with the deduction alternative
n. Program income expended in accordance with the addition alternative
o. Unexpended program income (line l minus line m or line n)
a. Type b. Rate c. Period From Period To d. Base e. Amount Charged f. Federal Share
11. Indirect
g. Totals:
12. Remarks: Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
13. Certification: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures,
disbursements and cash receipts are for the purposes and intent set forth in the award documents. I am aware that any false, fictitious, or fraudulent information
may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)
a. Typed or Printed Name and Title of Authorized Certifying Official c. Telephone (Area code, number and extension)
d. Email address
b. Signature of Authorized Certifying Official e. Date Report Submitted (Month, Day, Year)
14. Agency use only:
Standard Form 4255HYLVHG
OMB Approval Number: 0348-0061
Expiration Date: 10/31/2011
Paperwork Burden Statement
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The valid OMB control
number for this information collection is 0348-0061. Public reporting burden for this collection of information is estimated to average 1.5 hours per response, including time for reviewing instructions,
searching existing data sources, gathering 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 Management and Budget, Paperwork Reduction Project (0348-0061), Washington, DC 20503.
Reset Form