ICJIA MONTHLY FISCAL REPORT FORM

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					                                                         ICJIA MONTHLY FISCAL REPORT FORM

                                             For State Agencies receiving General Revenue Funds
Implementing Agency                                                                            Agreement #

Program Title                                                                                  Federal Employer ID #

Program Period                                                                                 Expense Report for the month of:


                                                                    FEDERAL FUNDS

                               (1)                       (2)             (3)                  (4)                (5)             (6)
     Budget              Project Budget              Cumulative     Expenses Paid         Cumulative         Unexpended      Projected
    Category                                        Expenses Last    This Month         Expenses To Date       Budget       Expenses for
                                                       Month                                 (2+3)              (1-4)       Next 60 Days
(A)
Personnel

(B)
Equipment

(C)
Commodities

(D)
Travel

(E)
Contractual

(F)
Other Costs

(G)
TOTAL




(H) TOTAL FEDERAL DOLLARS RECEIVED TO DATE


(I) FEDERAL CASH BALANCE [(H)-(4G)]


(J) FEDERAL FUNDS REQUESTED


(K) GENERAL REVENUE FUNDS REQUESTED


(L) INTEREST EARNED ON FEDERAL FUNDS TO DATE
       ___________________________________________
                                                                     CONTINUE ON BACK


ICJIA/FSGU USE ONLY

Recommended Disbursal                                               Approved By

Interest Income Applicable                                                Date




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                                                                         MATCHING FUNDS


                               (1)                        (2)                    (3)              (4)               (5)           (6)
     Budget              Project Budget               Cumulative            Expenses Paid     Cumulative        Unexpended    Projected
    Category                                         Expenses Last           This Month     Expenses To Date      Budget     Expenses for
                                                        Month                                    (2+3)             (1-4)     Next 60 Days
(M)
Personnel

(N)
Equipment

(O)
Commodities

(P)
Travel

(Q)
Contractual

(R)
Other Costs

(S)
TOTAL




(T) TOTAL MATCHING FUNDS CONTRIBUTED TO DATE


(U) MATCH CASH BALANCE [(T)-(4S)]


PROGRAM/ PROJECT INCOME

         (7)                            (8)                              (9)               (10)                (11)
    Forfeitures                    Fees Or Other                   Total Project       Total Project      Project Income
  Received To Date                    Income                          Income             Income              Balance
                                                                  Received To Date   Expended To Date         (9-10)
                                                                        (7+8)




CERTIFICATION

I certify that this is a true and accurate report.

Prepared By (Signature)                                                                                 Date

Approved By (Signature)                                                                                 Date


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