2010 ILLINOIS YES CLOSEOUT PACKAGE by 13ZgpL

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									                                                                                                                                FORM I
                          ILLINOIS YOUTH SUMMER EMPLOYMENT 2010
                                 PY - 10 CLOSEOUT SUMMARY
        Initial                                                                                                                For Profit
        Revision #                                                                                                             Not-For-Profit



Agency Name:                                           Address:                                          Phone Number:



Contract #:                                            Contact Person:                                   Fax Number:



Period covered by this close-out                 June 28, 2010 - September 30, 2010                      Email Address:

Program                        Final Award              Actual Costs          Contract Revenue                Income (Loss) 4(a), 4(b)



Case Management                            -                        -                        -                                              -

Worker Trainee Wages                       -                        -                        -                                              -

Worker Trainee FICA                        -                        -                        -                                              -
Worker Trainee
Workman Comp.                              -                        -                        -                                              -

Participant Support                        -                        -                        -                                              -



Total                                      -                        -                        -                                              -

                                                              DEFINITIONS

1.      Final Award:           The original contract award by title plus (minus) contract modifications.
2.      Actual Costs:          Total costs incurred to meet the contract objectives. This includes both the reimbursed and the un-reimbursed costs.
3.      Contract Revenue:      Actual receipts from FSS/Illinois Y.E.S with any accruals (unpaid reimbursable vouchers).
4.      Income:                Contract revenue in excess of actual costs.
                      (a)      See Addendum 1 Concerning the proper treatment of program income.
        (Loss):                Actual costs in excess of contract revenue.
                      (b)      See Addendum 2 Concerning the proper treatment of stand-in costs.

                                               Contract Closeout Certification Statement

I hereby certify, that to the best of my knowledge and belief, the Financial Statements contained in this Closeout Package accurately represent the
financial position of this grant. The statements are presented in conformity with General Accepted Accounting Principles, applicable State and
Federal rules, regulations and cost principles and there are no transactions that have not been properly recorded.


Authorized Official (Please Print)                                                                Authorized Signature




Title                                                                                             Date



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                                                                                                                                                       FORM II

                                               PY-10 ILLINOIS Y.E.S. LINE ITEM DETAIL OF EXPENDITURES
        - Initial                                                                                                                                  - For Profit
        - Revision # ______                                                                                                                        - Not-For-Profit



Agency Name:                                       -      Contract Number.:                       -           Agreement Period:   June 28, 2010 - September 30, 2010


 ACCT                  EXPENDITURES                      AWARD                    ACTUAL                        FSS                             INCOME
                                                                                                      REIMBURSED/REIMBURSABLE
  #                                                      AMOUNT               PROGRAM COSTS                    COSTS                             (LOSS)

  1                            2                           3                        4                            5                               6 (5 - 4)


 0005      Personnel (Case Management)                                                                                                                                 -


 0044      Fringe Benefits (Case Management)                                                                                                                           -


 0100      Operating / Technical (Case Management)                                                                                                                     -


 0140      Prof. & Tech. Services (Case Management)                                                                                                                    -


 0300      Material & Supplies (Case Management)                                                                                                                       -


 0400      Equipment (Case Management)                                                                                                                                 -


 0999      Other (Case Management)                                                                                                                                     -


           Subtotal (Case Management)                                  -                      -                              -                                         -


 0005      Worker-Trainee Wages                                                                                                                                        -


 0044      Worker Trainee - FICA                                                                                                                                       -


 0044      Worker-Trainee Worker Compensation                                                                                                                          -


 0999      Participant Supportive Services                                                                                                                             -


           TOTAL                                                       -                      -                              -                                         -


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                                                                                                                                                        FORM III

                               Department of Family and Support Services
                   CONTRACTOR'S PROPERTY INVENTORY FORM - ILLINOIS Y.E.S -PY10
                                  Period Covered 06/01/10 - 09/30/10

CONTRACT'S NAME                                                                              CONTRACT NUMBER

PREPARED BY                                                                                  FUND / ACTIVITY


                                                      EQUIPMENT PURCHASE / ACQUISITION INVENTORY LISTING
      TAG                                                                                             PURCHASE         PURCHASE               LOCATION OF
    NUMBER               DESCRIPTION         SERIAL NUMBER            VENDOR             CONDITION      DATE             PRICE                 PROPERTY




     TOTAL                                                                                                         $              -



IF ANY PROPERTY WITH AN ACQUISITION COST OF $5,000 OR MORE AND A LIFE EXPECTANCY OF ONE YEAR OR MORE HAS BEEN ACQUIRED DURING THIS GRANT PERIOD (06/01/10 - 09/30/10)
WITH WIA FUNDS, THE CONTRACTOR MUST INCLUDE THIS PROPERTY INVENTORY FORM. THIS IS A COMPLETE INVENTORY OF NON-EXPENDABLE PERSONAL PROPERTY ACQUIRED WITHIN
OR DURING THIS PERIOD ONLY.

IF NO PROPERTY HAS BEEN ACQUIRED, PLEASE INDICATE N/A ON FORM AND INCLUDE WITH SUBMISSION.


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                                                                                                              FORM IV


             Contractor's Assignment of Refunds, Rebates, and Credits

Contractor                                                                                              Grant #


Street Address


City / State / Zip Code

     Pursuant to the terms of Grant Agreement Number                                                and in consideration
     of the reimbursement of costs and payment of fees, as provided in the said Grant and any assignment there under, the




                                              (Contractor's Name and Address)

     hereinafter called the Contractor, does hereby:



 *   Assign, transfer, set over and release to the department of Family and Support Services all rights, title and interest to
     all refunds and credits or other amounts (including any interest thereon) due or which may become due, and forward
     promptly to FSS checks (made payable to "City of Chicago") for any proceeds so collected.
     The reasonable costs of any action to effect this collection shall constitute allowable costs when approved
     by the grantor as stated in the said grant and may be applied to reduce any amounts otherwise payable to FSS
     under the terms hereof.



 *   Agree to cooperate fully with FSS as to any claims or suits in connection with such refunds and credits or other
     amounts due: to execute any protest, pleading, application, power of attorney or other papers in connection therewith,
     and to permit FSS to present it in any hearing, trial or other proceeding arising out of such claim or suit.




Authorized Signature                                                                                    Name (Please Print)




Title




Date


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                                                                                                        FORM V


                            FINANCIAL RECORD RETENTION


Contractor                                                                                    Grant #

We agree to provide by the following provisions:


Financial records must be retained for three years from the date of your final Financial Closeout Package.

Unresolved issues (which may include but are not limited to audit findings, litigation, and bankruptcy)
would necessitate a longer retention period. The three-year-clock would be adjusted after resolution of
the issue and/or submission of a revised closeout package.

                                                Access to Records

Authorized representatives of the U.S. Department of Labor and the Awarding agency shall have timely
and reasonable access to any pertinent books, documents, papers, or other records of the awardee in order
to make audits, examinations, excerpts, and transcripts.

I certify that to the best of my knowledge, the information contained on this form, and on all other
closeout forms and documents for the agreement indicated above, is correct and complete.


The Closeout Package has been executed this                       day of                      2010


Authorized Signature:

Type Name:

Title:

Telephone Number:


                                              For Internal Use Only


Reviewed by:                                                                          Date:
                                Grant Manager

Reviewed by:                                                                          Date:
                                     Fiscal

Approved by:                                                                          Date:
                                     Fiscal



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                                                                                                                          FORM VI

                                      WIA AGREEMENT CLOSE-OUT PACKAGE
                                                               Awardee's Release


Pursuant to the terms of Agreement #                                       , and in considersation of the expended and accrued sum of

                                   , of which                                is the amount paid and                                is the

amount to be paid under the said agreement with                                              hereinafter called the awardee or to its

assignees, if any, the awardee upon payment of the said                                      sum by the Department of Family and

Support Services hereinafter called the awarding entity does release and discharge the awarding entity, its officers, agents, and

employees, of any and all liabilities, obligations, claims, and demands whatsoever under or arising from the said agreement

except:



  *     Final closeout cost in stated amounts, or in estimated amounts where the exact amounts are not available by the
        awardee, as follows:


             Invoice                                 Invoice         Line Item                                               Expected
               Date                                     or           Account              Cost              Invoice          Payment
           (If Known)               Vendor            P.O. #             #              Category            Amount             Date




              TOTAL                                                                                     $             -



  *     Claims after closeout for cost which result from liabilities under the WIA program will not be paid after October 15, 2009
        including unemployment insurance costs and workers' compensation claims.


        This release has been executed this                       day of                     2010




Signature of Authorized Official                Type Name                                    Title



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