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2012Subawardee_Fiscal_Report_Form

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					                                                                                                                                             Sub-awardee Fiscal Report Form 1
                                                                                                                                                                                                                                                                          CHAPTER USE ONLY
  Sub-award Identification
                Number:                                                                                                                   Agency name:                                                                                                                                Approved By

         Authorized Agency
           Representative:                                                                                                            Organization City:                                                                                                                            Date Approved


    Fiscal Contact Person:                                                                                                           Organization State:

            Phone Number:                                                                                                                           Email:


Awarded Amount                  $10,000.00
                                                        Approved                                                                   Itemized Costs within each category                                                                                                                                   Balance
                                                         Budget          Expenditures per                (Itemize the costs included in each category. Give a brief description of each line item)                                                                                                    remaining per
                                    Requested          According to        category for                            In order to create a new line within a cell, please hit "Alt" and "Enter."                               Total Amount                                                              category after
         Categories                  Budget               BMR**              report 1                          Make sure to expand each row as necessary so all itemizations are visible.                                    Approved                Notes and Deductions from Chapter                   report 1
                                                                                            In this cell, please detail the employees' names, titles and requested amounts for their salaries.
Personnel                                                                                                                                                                                                                                                                                                $0.00

Fringe Benefits                                                                                                                                                                                                                                                                                          $0.00

Travel                                                                                                                                                                                                                                                                                                   $0.00

Equipment                                                                                                                                                                                                                                                                                                $0.00

Supplies                                                                                                                                                                                                                                                                                                 $0.00

Consultant/Contract (max
$56.25 per hour)                                                                                                                                                                                                                                                                                         $0.00

Other                                                                                                                                                                                                                                                                                                    $0.00

                                                                                                                                                                                                                                           Attention: If the cumulative percent of budget changes is over 10%, a
                       Totals         $0.00               $0.00               $0.00                                                                                                                                           $0.00        Budget Modification Request is required.


   Total amount approved by Chapter in report 1:                               $0.00                                                                                                                                                                     Cumulative percent moved:                  0.00%

               Grant Balance after reporting period 1:                     $10,000.00
                                **Prior to filling out the "Approved Budget Changes from BMR" column, you need to have an approved Budget Modification Request on file with your Chapter. This column should contain data submitted to and approved by your Chapter prior to
                                submitting this report.

                                Grantees may request modification to the approved budget in order to reallocate dollar amounts among budget categories within the existing award amount. The original award amount may not be increased by this procedure; however, it can be
                                decreased. Movement of dollars between approved budget categories without a BMR is allowable up to ten percent of the total award amount (the ten percent rule), provided there is no change in project scope.
Instructions:
1. For each line item (except personnel & fringe benefits) NCA requires at least two forms of supporting fiscal documentation that need to be included:
a. Proof of Expense: invoices, receipts or bills (copy of the document from the original vendor)
b. Proof of Payment: ledger (generated from an accounting system Peachtree, QuickBooks, etc.), canceled check, credit card/bank statement, or credit card receipt
c. Please cross reference both documents or attach them next to each other.

2. For Personnel and Fringe benefits NCA requires a proof of payment which could be any combination of the following : detailed ledgers, payroll documents, canceled checks, insurance invoices.

For more details for the required fiscal documentation, please see the rfiscal documentation sheet at http://www.nationalchildrensalliance.org/2011chaptergrantformsandreports

3. NCA can only reimburse travel expenses (mileage and lodging) at the Federal Per Diem rate. You can access Federal Per Diem rates at http://www.gsa.gov.

4. NCA can only reimburse expenses that were incurred during the grant cycle and are allowable expenses. The costs need to be directly related to the goals and objectives of the grant type and the grantee application.

5. Any other questions related to this form, please contact your Chapter representative.
If you used NCA grant funds to conduct/attend trainings, please give specifics and fill out the table below:
                                                                                                                                                                                                Attendees
                                      Dates of the                                                           Location                                             (please list only the MDT members/ CAC employees that are included
    Topic/Name of the training         Training    Travel Dates                                            (City, State)                                                                   in your grant report)




Please follow the survey link to the right in order to answer the
narrative questions for your grant reporting. If you are unable
to open the survey by clicking the link, copy and paste the link
into your browser.
                                                                        https://childrensmn.qualtrics.com/SE/?SID=SV_emQpdjKP7EDuweM
Important: After you submit your narrative form, you will
receive a confirmation email to the email address that you
enter. Please print the email and submit to your Chapter as
part of your grant report.


By submitting this information, I certify the accuracy of the information provided above:

                        Authorized Agency Representative Signature:


                          Authorized Agency Representative's Title:

Important: The Authorized Agency Representative must have signed the Cooperative Agreement . In case you have a change of staff please notify your Chapter before submitting the report. You MUST sign the report in the
boxes above with an electronic or handwritten signature.
                                                                                                                         Sub-awardee Fiscal Report Form 2
                                                                                                                                                                                                                                                        CHAPTER USE ONLY
  Sub-award Identification
                Number:                                                                                                                  Agency Name:                                                                                                               Approved By

         Authorized Agency
            Representative:                                                                                                           Organization City:                                                                                                          Date Approved


   Fiscal Contact Person:                                                                                                           Organization State:

            Phone Number:                                                                                                                         Email:



Awarded Amount                 $10,000.00

                                                 Balance        Approved                                                             Itemized Costs within each category                                                                                                              Balance
                                              remaining per      Budget       Expenditures per               (Itemize the costs included in each category. Give a brief description of each line item)                                                                             remaining per
                                 Requested    category after   According to     category for                          In order to create a new line within a cell, please hit "Alt" and "Enter."         Total Amount                                                              category after
         Categories               Budget         report 1        BMR**            report 2                         Make sure to expand each row as necessary so all itemizations are visible.             Approved                Notes and Deductions from Chapter                   report 2
                                                                                                 In this cell, please detail the employees' names, titles and requested amounts for their salaries.


Personnel                         $0.00          $0.00                                                                                                                                                                                                                                 $0.00




Fringe Benefits                   $0.00          $0.00                                                                                                                                                                                                                                 $0.00




Travel                            $0.00          $0.00                                                                                                                                                                                                                                 $0.00




Equipment                         $0.00          $0.00                                                                                                                                                                                                                                 $0.00




Supplies                          $0.00          $0.00                                                                                                                                                                                                                                 $0.00


Consultant/
Contract (max $56.25
per hour)                         $0.00          $0.00                                                                                                                                                                                                                                 $0.00




Other                             $0.00          $0.00                                                                                                                                                                                                                                 $0.00

                                                                                                                                                                                                                        Attention: If the cumulative percent of budget changes is over 10%, a
                      Totals      $0.00          $0.00           $0.00            $0.00                                                                                                                    $0.00        Budget Modification Request is required.



                      Total amount approved by Chapter in report 2:               $0.00                                                                                                                                               Cumulative percent moved:                   0.00%

                                 Grant Balance after reporting period 2:       $10,000.00



                               **Prior to filling out the "Approved Budget Changes from BMR" column, you need to have an approved Budget Modification Request on file with your Chapter. This column should contain data submitted to
                               and approved by your Chapter prior to submitting this report.
                               Grantees may request modification to the approved budget in order to reallocate dollar amounts among budget categories within the existing award amount. The original award amount may not be increased
                               by this procedure; however, it can be decreased. Movement of dollars between approved budget categories without a BMR is allowable up to ten percent of the total award amount (the ten percent rule),
                               provided there is no change in project scope.
Instructions:
1. For each line item (except personnel & fringe benefits) NCA requires at least two forms of supporting fiscal documentation that need to be included:
a. Proof of Expense: invoices, receipts or bills (copy of the document from the original vendor)
b. Proof of Payment: ledger (generated from an accounting system Peachtree, QuickBooks, etc.), canceled check, credit card/bank statement, or credit card receipt
c. Please cross reference both documents or attach them next to each other.

2. For Personnel and Fringe benefits NCA requires a proof of payment which could be any combination of the following : detailed ledgers, payroll documents, canceled checks, insurance invoices.

For more details for the required fiscal documentation, please see the rfiscal documentation sheet at http://www.nationalchildrensalliance.org/2011chaptergrantformsandreports

3. NCA can only reimburse travel expenses (mileage and lodging) at the Federal Per Diem rate. You can access Federal Per Diem rates at http://www.gsa.gov.

4. NCA can only reimburse expenses that were incurred during the grant cycle and are allowable expenses. The costs need to be directly related to the goals and objectives of the grant type and the grantee application.

5. Any other questions related to this form, please contact your Chapter representative.
If you used NCA grant funds to conduct/attend trainings, please give specifics and fill out the table below:
                                                                                                                                                                                                                 Attendees
                                      Dates of the                                                                           Location                                              (please list only the MDT members/ CAC employees that are included
    Topic/Name of the training         Training             Travel Dates                                                   (City, State)                                                                    in your grant report)




Please follow the survey link to the right in order to answer the narrative
questions for your grant reporting. If you are unable to open the survey by
clicking the link, copy and paste the link into your browser.
                                                                                       https://childrensmn.qualtrics.com/SE/?SID=SV_emQpdjKP7EDuweM
Important: After you submit your narrative form, you will receive a
confirmation email to the email address that you enter. Please print the email
and submit to your Chapter as part of your grant report.




By submitting this information, I certify the accuracy of the information provided above:

                                       Authorized Agency Representative Signature:


                                          Authorized Agency Representative's Title:

Important: The Authorized Agency Representative must have signed the Cooperative Agreement . In case you have a change of staff please notify your Chapter before submitting the report. You MUST sign the report in the boxes above with an
electronic or handwritten signature.

				
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posted:8/29/2012
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