American Rescue Plan Financial Report

American Rescue Plan Financial Report
Primary Contact

Please provide the primary contact person for the submission of this report.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Company/Organization Name*
What is the best way to reach you?*

By PhoneBy Email
Recipient Organization Information
Recipient Organization Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Business Phone Number*
Please enter a valid phone number.
DUNS #
Employer Identification Number (EIN)
Recipient Account Number or Identifying Number
Financial Report Type*

QuarterlySemi-AnnualAnnualFinal
Project/Grant Period Start Date*

MonthDayYear
Date
Project/Grant Period End Date*

MonthDayYear
Date
Reporting Period End Date*

MonthDayYear
Date
Transactions
Project Name*

Project Financials*

	Amount in Dollars
Cash Receipts (line a)
Cash Disbursements (line b)
Cash on Hand (line a minus line b)

Financial Report Certification
Full Name of Authorized Certifying Official*

PrefixFirst NameMiddle NameLast Name
Title of Authorized Certifying Official*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
By signing this report, I certify that this is true, complete and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil or administrative penalties. US Code, Title 18, Section 1001
Signature*

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Primary Contact