State of California

							State of California
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSBG CONTRACT
CLOSE-OUT CHECKLIST AND CERTIFICATION OF DOCUMENTS TRANSMITTED
CSD 715 (Rev. 02/12)

Contractor


Contract Number                                                Term



Submit this form and all documents listed below (if applicable) to CSD within ninety (90) calendar days after the
expiration date. Any monies due to CSD must be included in the close-out package.

1.     Refund Check Amount (if applicable) $________________ (This amount should match the amount entered on the
       Close-out Program Income/Interest Earned Expenditure Report form (CSD 715 C) Item 3)
              Not Applicable

2.     CSBG Close-out Fiscal Data - Adjustments (Use EARS Reporting System and attach a listing of the months
       adjusted and amounts.)
              Close-out adjustments: submit all expenditure adjustments into the Expenditure Activity Reporting
               System. (All adjustments must be made in the report period in which they occurred.)
              Not Applicable

3.     CSBG Close-out Program Income/Interest Earned Expenditure Report
              CSD 715C (Rev. 02/12)
              Not Applicable

4.     CSBG Close-out Equipment Inventory Schedule
              CSD 715D (Rev. 02/12)
              Not Applicable

Comments:



                                             CERTIFICATION
   THE SIGNATURE BELOW CERTIFIES THAT THE INFORMATION SUBMITTED IN THE CSBG CLOSE-OUT IS ACCURATE,
              COMPLETE, AND REVIEWED AND APPROVED BY THE AGENCY’S AUTHORIZED AGENT.
Name                                                 Telephone Number
                                                     (      )
Signature                                                      Date