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 ( 0348-0060), Washington, DC 20503.
Standard Form 425
OMB Approval Number: 0348-0061
Expiration Date: 10/31/2011
1. Federal Agency and Organizational Element
to Which Report is Submitted
2. Federal Grant or Other Identifying Number Assigned by Federal Agency
(To report multiple grants, use FFR Attachment)
5. Recipient Account Number or Identifying Number
(To report multiple grants, use FFR Attachment)
Cumulative
(Use lines a - c for single or multiple grant reporting)
Federal Cash (To report multiple grants, also use FFR Attachment):
(Use lines d - o for single grant reporting)
Federal Expenditures and Unobligated Balance:
Recipient Share:
Program Income:
a. Type
b. Rate
c. Period From
Period To
d. Base
e. Amount Charged
f. Federal Share
11. Indirect
g. Totals:
13. Certification: By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge. 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)