Texas Department of Agriculture Education Service Center Budget Reimbursement Request
Todd Staples, Commissioner
SECTION A
FND-118
Education Service Center (ESC) Region Federal Fiscal Year Name of ESC Executive Director Name of ESC Financial Director
Expenditures and Program Income
1
TDA Class/Obj Code
6100 6101 6102 6103 6104
Original Budget Request
TDA Approved Budget
1st Quarter Reimbursement Request
2nd Quarter Reimbursement Request
3rd Quarter Reimbursement Request
4th Quarter Reimbursement Request
Balance Remaining
OPERATING BUDGET Payroll Costs Contracted Services Operational/Administrative Travel Capital Outlay Total Direct Operating Expenditures $ $ $ $ $ $
6110 6111 6112
1 2 3 4 5 6
2
-
SECTION B
-
$
-
$
-
$
-
$
-
$
-
$
WORKSHOPS Contracted Services Operational/Administrative Travel Total Workshop Expenditures TOTALS Total Operating and Workshop Expenditures Indirect Cost Total Expenditures with Indirect Costs Program Income Reimbursable Expenditures
6199 6198
7 8 9 10
3
$ $ $ $ $ $ $ $ $ $
-
11 12 13 14 15
$
-
$
-
$
-
$
-
$
-
$
-
$ $
-
$
-
$
-
$
-
$
-
$
-
$
-
$ $
$
-
$
-
$
-
$
-
$
-
$
-
$
1
SECTION C
CERTIFICATION STATEMENT
Name and Title of Authorized Official Telephone Number Signature of Authorized Official
I hereby certify that this report is true and correct and that budgeted amounts reported are for appropriate purposes and in accordance with the provisions of the contract.
Name of Preparer
Telephone Number
Date Signed (mm/dd/yyyy)
SECTION D
1
TDA INTERNAL USE ONLY TDA Signature Approval
Date Approved
This document becomes public record and is subject to disclosure. With few exceptions, you have the right to request and be informed about the information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. (Reference: Government Code, Sections 552.021, 552.023, and 559.004.)
Food and Nutrition Division
Revised 9/1/06