Form FS-91 "Statement of Interest Earned From Advance Payments Deposited Into an Interest Bearing Account" - New Jersey

What Is Form FS-91?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2012;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FS-91 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form FS-91 "Statement of Interest Earned From Advance Payments Deposited Into an Interest Bearing Account" - New Jersey

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New Jersey Department of Health
Financial Services
P.O. Box 360
Trenton, NJ 08625-0360
STATEMENT OF INTEREST EARNED FROM ADVANCED PAYMENTS
DEPOSITED INTO AN INTEREST BEARING ACCOUNT
This statement is to be submitted on an annual basis and will be due no later than 20 days after the end of the agency’s fiscal year.
Only one statement is required to be submitted for all Grants awarded to your agency.
SUBMIT THIS FORM ALONG WITH CHECK TO ABOVE ADDRESS
NAME OF AGENCY
FEDERAL ID NUMBER
ADDRESS
AGENCY’S FISCAL YEAR ENDS:
NJDOH GRANT(S):
INTEREST BEARING ACCOUNT NO.:
NAME OF BANK
BRANCH NAME
Interest Earned
Amount
Total Interest Earned During Fiscal Year Ending
Less $250 ...................................................................................................
Balance To Be Remitted.............................................................................
I certify that an interest bearing account has been established.
All funds received are deposited upon receipt to this account.
NAME (Print)
SIGNATURE
DATE
In accordance with Subpart F of the “Terms and Conditions for Administration of Grants”, dated January 1, 1998, for
grants that are less than $100,000, grantees will not be required to return interest on advance funds, but if a grantee
chooses to deposit the grant funds into an interest bearing account, then the grantee must submit any interest
earned over $250 to the Department. If a grantee receives one grant for $100,000 or more, all grant funds received
on this and other grants awarded on the advanced payment system must be deposited into an interest bearing
account. Any interest earned over $250 must be submitted directly to the Office of Financial Services of the New
Jersey Department of Health at the address listed above. The grantee may keep interest amounts up to $250 per
year for administrative expenses.
FS-91
AUG 12
New Jersey Department of Health
Financial Services
P.O. Box 360
Trenton, NJ 08625-0360
STATEMENT OF INTEREST EARNED FROM ADVANCED PAYMENTS
DEPOSITED INTO AN INTEREST BEARING ACCOUNT
This statement is to be submitted on an annual basis and will be due no later than 20 days after the end of the agency’s fiscal year.
Only one statement is required to be submitted for all Grants awarded to your agency.
SUBMIT THIS FORM ALONG WITH CHECK TO ABOVE ADDRESS
NAME OF AGENCY
FEDERAL ID NUMBER
ADDRESS
AGENCY’S FISCAL YEAR ENDS:
NJDOH GRANT(S):
INTEREST BEARING ACCOUNT NO.:
NAME OF BANK
BRANCH NAME
Interest Earned
Amount
Total Interest Earned During Fiscal Year Ending
Less $250 ...................................................................................................
Balance To Be Remitted.............................................................................
I certify that an interest bearing account has been established.
All funds received are deposited upon receipt to this account.
NAME (Print)
SIGNATURE
DATE
In accordance with Subpart F of the “Terms and Conditions for Administration of Grants”, dated January 1, 1998, for
grants that are less than $100,000, grantees will not be required to return interest on advance funds, but if a grantee
chooses to deposit the grant funds into an interest bearing account, then the grantee must submit any interest
earned over $250 to the Department. If a grantee receives one grant for $100,000 or more, all grant funds received
on this and other grants awarded on the advanced payment system must be deposited into an interest bearing
account. Any interest earned over $250 must be submitted directly to the Office of Financial Services of the New
Jersey Department of Health at the address listed above. The grantee may keep interest amounts up to $250 per
year for administrative expenses.
FS-91
AUG 12