ࡱ> '` bjbj{P{P N::r>&&&&555826L~6RV9l9L999:::QQQQQQQ$ShVR:::::R&&994+R$AAA:6&99QA:QAA: F,6F9J9 `;p5*<LF GT ORxRVFRV<VFVF::A:::::RR>:::R::::-55&&&&&&+R Each grantee receiving at least $1 and less than $25,000 should complete the basic information requested here relative to the organization, as well as the accounting for State funds received, used or expended, and a description of activities and accomplishments undertaken by the grantee with the State funds.  This information should be completed and submitted by all grantees receiving any amount less than $25,000.Organization:Name:Tax Identification #:Organization Fiscal Year End: (mmddyyyy)Mailing Address (street, city, state, zip code):Phone Number (area code + number):Fax Number (area code + number):Contact Person:Contact Person Title:E-Mail Address: Preparer: [please indicate who prepared this information by checking]EmployeeCPA/AccountantName of Preparer:Phone Number: Please provide a list of the Organizations Board Members. [add additional pages, if needed]Name of Board MemberBoard Member Title GS. 143-6.2 (repealed June 30, 2007), G.S. 143C-6-23 (effective July 1, 2007) and the North Carolina Administrative Code 09 NCAC 03M requires that every non-State entity that receives, uses, or expends any State funds shall use or expend the funds only for the purposes for which they were appropriated, and that the grantee must have a Conflict of Interest Policy. Please answer the following questions:Does the grant award document(s) place any restrictions on the grant funds? [check one]yesnoIf yes, list grants:Contract #Brief Description of RestrictionsDoes the organization have a Conflict of Interest policy? yesnoIs the organization a for profit entity?yesno G.S. 143-6.2 (repealed June 30, 2007), G.S. 143C-6-23 (effective July 1, 2007) and the North Carolina Administrative Code 09 NCAC 03M requires that every non-State entity that receives, uses, or expends any State funds shall use or expend the funds only for the purposes for which they were appropriated, and if the grantee then subgrants or pass any or part of those funds to another organization, then the granting organization must also pass on the reporting requirements to the subgrantee. Please answer the following questions:Did the organization subgrant or pass down any funds to another organization? yesnoIf yes, answer the following:a. Name of subgranteeb. Program namec. Amount subgranted Financial Accounting: [Complete based on total dollars received from the State, listing all State agencies that granted funds to your organization using the cash basis.]a. Receipts:Funding State AgencyPrograms/TitleContract #Program Total1$2$3$4$5$Total Receipts:$ b. Expenditures:CatagoryProgram 1Program 2Program 3Program 4Program 5Salary/Wages/Benefits$$$$$Contracted ServicesSupplies and MaterialsTravel (example: employee mileage, meals, hotel)Communication Costs (example: telephone, postage, freight)Occupancy Costs (example: rent, utilities, repair and maintenance)Advertising and PromotionsInsurance and BondingCapital Outlay (example: furniture/equipment, data processing)Grants and ContractsFundraisingOther Expenses: (list)Total Expenditures:$$$$$ Unexpended Grant Balance Available for Expenditure: Beginning of the year$$$$$End of the year$$$$$ Program Activities and Accomplishments:In compliance with the requirements of G.S. 143-6.2, Use of State funds by non-State entities, (repealed June 30, 2007) and G.S. 143C-6-23, State grant funds: administration, oversight and reporting requirements, (effective July 1, 2007), the following is a description of activities and accomplishments undertaken by our organization using the provided state funding:Program NameOriginal GoalsBrief Narrative of Program Accomplishments  If there are any questions, please contact the state agency that provided your grant. 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