ATTACHMENT III - LVER SF 424A Example (Original, Front) State: State Name Grant Number

:
SECTION A - BUDGET SUMMARY

Grant Number
OMB Approval No. 0348-0044

BUDGET INFORMATION - Non-Construction Programs

Grant Program Function or Activity (a)

Catalog of Federal Domestic Assistance Number (b)

Estimated Unobligated Funds Federal (c) Non-Federal (d) Federal (e)

New or Revised Budget Non-Federal (f)

1. LVER Activities 2. Special Initiatives 3. Incentive Awards 4. TAP 5. Totals

17.8

$2,997,880 $0 $2,997,880

SECTION B - BUDGET CATEGORIES

GRANT PROGRAM, FUNCTION OR ACTIVITY

6. Object Class Categories
(1) LVER Activities (2) Special Initiatives (3) Incentive Awards (4) TAP

a. Personnel b. Fringe Benefits c. Travel d. Equipment e. Supplies f. Contractual g. Construction h. Other i. Total Direct Charges (sum of 6a-6h) j. Indirect Charges k. TOTALS (sum of 6i and 6j) 7. Program Income
Previous Edition Usable

$1,730,623 $651,147 $7,571 $250 $1,185

$471,542 $2,862,318 $135,562 $2,997,880 $0 $0

Authorized for Local Reproduction

Standard Form 424A (Rev. 7-9

Prescribed by OMB Circular A-1

ATTACHMENT III - LVER SF 424A Example (Original, Front)

Approval No. 0348-0044

vised Budget Rounded Total (g)

$2,998,000 $0 $0 $2,998,000

Total (5)

$1,730,623 $651,147 $7,571 $250 $1,185 $0 $0 $471,542 $2,862,318 $135,562 $2,997,880

Standard Form 424A (Rev. 7-97) Prescribed by OMB Circular A-102

ATTACHMENT III - LVER SF 424A Example (Original, Front)

ATTACHMENT III - LVER SF 424A Example (Original, Back) State: State Name Grant Number: Grant Number
SECTION C - NON-FEDERAL RESOURCES
(a) Grant Program (b) Applicant (c) State (d) Other Sources (e) TOTALS

8. 9. 10.

11.
12. TOTAL (sum of lines 8-11)

SECTION D - FORECASTED CASH NEEDS
Total for Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

13. Federal (LVER)

$749,600
14. Non-Federal
15. TOTAL (rounded to nearest thousand)

$749,600

$749,340

$749,340

$2,998,000

$750,000

$750,000

$749,000

$749,000

SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
FUTURE FUNDING PERIODS (Years) (a) Grant Program (b) First (c) Second (d) Third (e) Fourth (f) (g) Total

SECTION F - OTHER BUDGET INFORMATION

21. Direct Charges: 23. Remarks

22. Indirect Charges Authorized for Local Reproduction
Standard Form 424A (Rev. 7-97) Page 2

ATTACHMENT III - LVER SF 424A Example (Baseline, Front) State: State Name Grant Number:
SECTION A - BUDGET SUMMARY

Grant Number
OMB Approval No. 0348-0044

BUDGET INFORMATION - Non-Construction Programs

Grant Program Function or Activity (a)

Catalog of Federal Domestic Assistance Number (b)

Estimated Unobligated Funds Federal (c) Non-Federal (d) Federal (e)

New or Revised Budget Non-Federal (f)

1. LVER Activities 2. Special Initiatives 3. Incentive Awards 4. TAP 5. Totals

17.8

$2,997,880 $0 $2,997,880

SECTION B - BUDGET CATEGORIES

GRANT PROGRAM, FUNCTION OR ACTIVITY

6. Object Class Categories
(1) LVER Activities (2) Special Initiatives (3) Incentive Awards (4) TAP

a. Personnel b. Fringe Benefits c. Travel d. Equipment e. Supplies f. Contractual g. Construction h. Other i. Total Direct Charges (sum of 6a-6h) j. Indirect Charges k. TOTALS (sum of 6i and 6j) 7. Program Income
Previous Edition Usable

$1,730,623 $651,147 $7,571 $250 $1,185

$52,698 $18,452 $1,258

$5,542 $1,833 $761 $0 $0

$471,542 $2,862,318 $135,562 $2,997,880

$16,582 $88,990 $8,965 $97,955 $0 $0

$4,106 $12,242 $987 $13,229

Authorized for Local Reproduction

Standard Form 424A (Rev. 7-9

Prescribed by OMB Circular A-1

Added $98,000 to Special Initiatives $13,000 to TAP allocated to the 3rd and 4th quarters.

ATTACHMENT III - LVER SF 424A Example (Baseline, Front)

Approval No. 0348-0044

vised Budget Rounded Total (g)

$2,998,000 $98,000 $13,000 $3,109,000

Total (5)

$1,788,863 $671,432 $9,590 $250 $1,185 $0 $0 $492,230 $2,963,550 $145,514 $3,109,064

Standard Form 424A (Rev. 7-97) Prescribed by OMB Circular A-102

Added $98,000 to Special Initiatives $13,000 to TAP allocated to the 3rd and 4th quarters.

ATTACHMENT III - LVER SF 424A Example (Baseline, Front)

Added $98,000 to Special Initiatives $13,000 to TAP allocated to the 3rd and 4th quarters.

ATTACHMENT III - LVER SF 424A Example (Baseline, Back) State: State Name Grant Number: Grant Number
SECTION C - NON-FEDERAL RESOURCES
(a) Grant Program (b) Applicant (c) State (d) Other Sources (e) TOTALS

8. 9. 10.

11.
12. TOTAL (sum of lines 8-11)

SECTION D - FORECASTED CASH NEEDS
Total for Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

13. Federal (LVER) 14. Non-Federal
15. TOTAL (LVER) (rounded to nearest thousand)

$2,998,000

$750,000

$750,000

$749,000

$749,000

SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
FUTURE FUNDING PERIODS (Years) (a) Grant Program (b) First (c) Second (d) Third (e) Fourth (f) (g) Total

16. LVER Activities 17. Special Initiatives 18. TAP 19. Incentive Awards
20. TOTAL (lines 15-19)

$0

$0

$0 $37,955 $5,070

$0 $60,000 $8,159 $817,000 $0

$0 $97,955 $13,229 $0 $3,109,000

$750,000

$750,000

$792,000

SECTION F - OTHER BUDGET INFORMATION

21. Direct Charges: 23. Remarks

22. Indirect Charges Authorized for Local Reproduction
Standard Form 424A (Rev. 7-97) Page 2

Added $98,000 to Special Initiatives and $13,000 to TAP allocated to the 3rd and 4th quarters.

ATTACHMENT III - LVER SF 424A Example (Modified, Front) State: State Name Grant Number:
SECTION A - BUDGET SUMMARY

Grant Number
OMB Approval No. 0348-0044

BUDGET INFORMATION - Non-Construction Programs

Grant Program Function or Activity (a)

Catalog of Federal Domestic Assistance Number (b)

Estimated Unobligated Funds Federal (c) Non-Federal (d) Federal (e)

New or Revised Budget Non-Federal (f)

1. LVER Activities 2. Special Initiatives 3. Incentive Awards 4. TAP 5. Totals

17.8

$2,997,880 $0 $2,997,880

SECTION B - BUDGET CATEGORIES

GRANT PROGRAM, FUNCTION OR ACTIVITY

6. Object Class Categories
(1) LVER Activities (2) Special Initiatives (3) Incentive Awards (4) TAP

a. Personnel b. Fringe Benefits c. Travel d. Equipment e. Supplies f. Contractual g. Construction h. Other i. Total Direct Charges (sum of 6a-6h) j. Indirect Charges k. TOTALS (sum of 6i and 6j) 7. Program Income
Previous Edition Usable

$1,430,623 $651,147 $7,571 $250 $1,185

$66,698 $24,589 $1,902

$6,852 $1,833 $675 $0 $0

$661,542 $2,752,318 $245,562 $2,997,880

$22,568 $115,757 $12,568 $128,325 $0 $0

$2,584 $11,944 $1,285 $13,229

Authorized for Local Reproduction

Standard Form 424A (Rev. 7-9

Prescribed by OMB Circular A-1

Modifies a previously modified grant request by adding $30,000 to Special Initiatives to be allocated in the 4th quarter.

ATTACHMENT III - LVER SF 424A Example (Modified, Front)

Approval No. 0348-0044

vised Budget Rounded Total (g)

$2,998,000 $128,000 $13,000 $3,139,000

Total (5)

$1,504,173 $677,569 $10,148 $250 $1,185 $0 $0 $686,694 $2,880,019 $259,415 $3,139,434

Standard Form 424A (Rev. 7-97) Prescribed by OMB Circular A-102

Modifies a previously modified grant request by adding $30,000 to Special Initiatives to be allocated in the 4th quarter.

ATTACHMENT III - LVER SF 424A Example (Modified, Front)

Modifies a previously modified grant request by adding $30,000 to Special Initiatives to be allocated in the 4th quarter.

ATTACHMENT III - LVER SF 424A Example (Modified, Back) State: State Name Grant Number: Grant Number
SECTION C - NON-FEDERAL RESOURCES
(a) Grant Program (b) Applicant (c) State (d) Other Sources (e) TOTALS

8. 9. 10.

11.
12. TOTAL (sum of lines 8-11)

SECTION D - FORECASTED CASH NEEDS
Total for Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

13. Federal (LVER) 14. Non-Federal
15. TOTAL (LVER) (rounded to nearest thousand)

$3,109,000

$750,000

$750,000

$792,000

$817,000

SECTION E - BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
FUTURE FUNDING PERIODS (Years) (a) Grant Program (b) First (c) Second (d) Third (e) Fourth (f) (g) Total

16. LVER Activities 17. Special Initiatives 18. TAP 19. Incentive Awards
20. TOTAL (lines 15-19)

$0 $30,000 $30,000 $0 $0 $750,000 $750,000 $792,000 $847,000 $0 $3,139,000
SECTION F - OTHER BUDGET INFORMATION

21. Direct Charges: 23. Remarks

22. Indirect Charges Authorized for Local Reproduction
Standard Form 424A (Rev. 7-97) Page 2

Modifies a previously modified grant request by adding $30,000 to Special Initiatives to be allocated in the 4th quarter.