Reset Form
Michigan Department of Treasury
Form 4972 (04-12)
Economic Vitality Incentive Program (EVIP) Grant Financial Status Report (FSR)
Completion is a condition of the grant under authority of Public Act 63 of 2011, as repealed and replaced by Public Act 278 of 2011.
SEE PAGE 2 FOR INSTRUCTIONS
PART 1: PROJECT INFORMATION
1. Grant Number
2. Project Title
3. Primary Local Unit Name
4. Telephone Number
5. Mailing Address
City
State
ZIP Code
6. Period Start Date
7. Period End Date
8. Report Type
10. Estimated Completion Date
9. Percentage Completed
%
Quarterly
Final
PART 2: FINANCIAL REPORTING
C. Projected Future
D. Total Projected
B. Amount Incurred to
E. Approved Original or
F. Difference Between
A. Budget Category
Expenditures to be
Expenditures for
Date
Amended Budget
Projection and Budget
Incurred
Project
$0
$0
11. Feasibility Study
$0
$0
12. Contracted Services
$0
$0
13. Administration
$0
$0
14. Training
$0
$0
15. Merger Expenses
16. Infrastructure/
$0
$0
Equipment
$0
$0
17. Other
18. ADJUSTMENTS DUE
TO OTHER FUNDING-
Reimbursements by other
(
) (
) (
) (
) (
)
funding sources or the use of
$0
$0
cash on hand
19. TOTAL AMOUNTS-
Sum of amounts shown in
$0
$0
the column
PART 3: CERTIFICATION
I hereby certify that the information in this financial status report is complete and accurate and all expenditures which are presented are for eligible
scope items as defined in the Final Grant Award Letter for the above project, and that all expenditures have been made during the project period
as listed in the Final Grant Award Letter, and are identified and filed according to accounting procedures set forth by the Michigan Department of
Treasury.
Printed Name of Primary Local Unit Chief Financial Officer
Title
Signature of Primary Local Unit Chief Financial Officer
Date
Reset Form
Michigan Department of Treasury
Form 4972 (04-12)
Economic Vitality Incentive Program (EVIP) Grant Financial Status Report (FSR)
Completion is a condition of the grant under authority of Public Act 63 of 2011, as repealed and replaced by Public Act 278 of 2011.
SEE PAGE 2 FOR INSTRUCTIONS
PART 1: PROJECT INFORMATION
1. Grant Number
2. Project Title
3. Primary Local Unit Name
4. Telephone Number
5. Mailing Address
City
State
ZIP Code
6. Period Start Date
7. Period End Date
8. Report Type
10. Estimated Completion Date
9. Percentage Completed
%
Quarterly
Final
PART 2: FINANCIAL REPORTING
C. Projected Future
D. Total Projected
B. Amount Incurred to
E. Approved Original or
F. Difference Between
A. Budget Category
Expenditures to be
Expenditures for
Date
Amended Budget
Projection and Budget
Incurred
Project
$0
$0
11. Feasibility Study
$0
$0
12. Contracted Services
$0
$0
13. Administration
$0
$0
14. Training
$0
$0
15. Merger Expenses
16. Infrastructure/
$0
$0
Equipment
$0
$0
17. Other
18. ADJUSTMENTS DUE
TO OTHER FUNDING-
Reimbursements by other
(
) (
) (
) (
) (
)
funding sources or the use of
$0
$0
cash on hand
19. TOTAL AMOUNTS-
Sum of amounts shown in
$0
$0
the column
PART 3: CERTIFICATION
I hereby certify that the information in this financial status report is complete and accurate and all expenditures which are presented are for eligible
scope items as defined in the Final Grant Award Letter for the above project, and that all expenditures have been made during the project period
as listed in the Final Grant Award Letter, and are identified and filed according to accounting procedures set forth by the Michigan Department of
Treasury.
Printed Name of Primary Local Unit Chief Financial Officer
Title
Signature of Primary Local Unit Chief Financial Officer
Date
Form 4972, Page 2
Instructions for Form 4972
Economic Vitality Incentive Program Grant Financial Status Report
The numbers listed below coincide with the numbers on the Grant Financial Status Report. Lines not listed are explained on the form.
PART 1: PROJECT INFORMATION
1. Grant Number: Fill in the respective grant number that was assigned by the Michigan Department of Treasury.
2. Project Title: Short name that was used on the grant application to describe the project.
3. Primary Local Unit Name: the Primary Local Unit that has the authority and the responsibility for the administration of
the project in accordance with the project conditions. For example, “City of Blank” is acceptable.
4. Telephone Number: Phone number, including area code, of the Primary Local Unit.
5. Mailing Address: Street number and name, including suite number if applicable, of the Primary Local Unit.
6. Period Start Date: Indicate the quarterly period start date of this report. For the FINAL report, indicate the start date of
the grant (i.e. 10/01/2011).
7. Period End Date: Indicate the quarterly period end date of this report. For the FINAL report, indicate the end date of
the grant (i.e. actual project completion date).
8. Report Type: Check whether this is a quarterly or the final report.
9. Percentage Completed: Indicate the estimated percentage (%) completed of the project work plan.
10. Estimated Completion Date: Indicate the estimated project completion date. For the FINAL report, indicate the actual
project completion date.
PART 2: FINANCIAL REPORTING
Lines 11 -17: Enter eligible costs incurred to date for each budget category. Eligible costs entered for lines 11 and 16
should reflect the state match only, 25% for feasibility study expenses and 50% for infrastructure/equipment expenses.
Column A: These are the approved budget categories from the Final Grant Award Letter.
Column B: Enter the cumulative allowable amount(s) incurred to date (from project inception).
Column C: Enter the projected amount(s) to be incurred in the future.
Column D: Sum of Column B and Column C.
Column E: Enter the approved budget for each category from the Final Grant Award Letter or Amended Budget Letter.
Column F: Subtract Column E from Column D.
Return this completed report within thirty (30) days after the end of the quarter (i.e. due by January 30th; April 30th; July
30th; October 30th). FINAL reports are due within thirty (30) days after the completion of the project.
Return this completed report to:
Michigan Department of Treasury
Office of Revenue and Tax Analysis
PO Box 30722
Lansing, MI 48909
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