Organization Financial Report
Adm. = Administrative Promo = Promotion Serv. = Services NSIP = YTD = Year to date
A. Organization information
AAA name
Project name
Address
City
Reported period
Grant period
Beginning
Ending
I certify that the information contained in this statement is accurate to the best of my knowledge, that all adjustments are completely accounted for, and that all costs reported herein were accrued in accordance with the conditions of this grant.
Signature of grantee official
Date
B. Grant award information
III-B services
III-D health promo
III-E adm./ caregiver
III-B adm.
III-C1 adm./serv.
III-C2 adm./serv.
Total Title III
Total Title VII
NSIP
1. Title III, VII, and NSIP grant awards
C. Cumulative revenues by program
III-B services
III-D health promo
III-E adm./ caregiver
III-B adm.
III-C1 adm./serv.
III-C2 adm./serv.
Total Title III
Total Title VII
NSIP
1. Title III, VII, and NSIP received - YTD
2. Grantee cash contributed - YTD
3. Program income - YTD
4. Total income YTD (C1+C2+C3)
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D. Cumulative disbursements by program
Title III service
Title III AAA administration
Title VII
NSIP
Cost categories
III-B services
III-C1 congregate
meals
III-C2 home del meals
III-D health promo
III-E adm/ caregiver
III-B adm. funds
III-C1 adm. funds
III-C2 adm. funds
Total Title III
Abuse prevention
Cash in lieu
1.
Personnel
2.
Travel
3.
Food
4.
Nutrition consultant
5.
Equipment
6.
Rent/utilities
7.
Other costs
8.
Alter/new construction
9.
Indirect costs
10.
Total costs
E. Cash balance and grant remaining
Title III service
Title III AAA administration
Title VII
NSIP
Cost categories
III-B services
III-C1 congregate meals
III-C2 home del meals
III-D health promo
III-E adm/ caregiver
III-B adm. funds
III-C1 adm. funds
III-C2 adm. funds
Total Title III
Abuse prevention
Cash in lieu
1.
Cash balance on hand (C4 - D10)
2.
Total grant unearned (B1 + C2 + C3 - D10)
