(use the cursor keys or tab key to move between form fields)

1.	Organization name (Recipient):	     	
2.	Federal employer ID number:	     	
3.	Grant number:	     	
4.	Grant start date:	     	
5.	Funding closes on:	     	
6.	Final report (yes, no):		
7.	Period covered by this report:	From:      	To:      	
	
8.	Transactions:		Previous period	This period	Cumulative	
Outlays	a.	Total:	     	     	     	
	b.	Recipient share:	     	     	     	
	c.	State share:	     	     	     	
Unliquidated obligations	d.	Total:	     	     	     	
	e.	Recipient share:	     	     	     	
	f.	State share:	     	     	     	
g.	Total state share (line c plus line f):	     	     	     	
h.	Maximum grant amount:	     	
i.	Unobligated balance of state funds:
(line h minus line g)	     	     	     	
	
9.	Remarks: 	     	
10.	Certification: 	I certify to the best of my knowledge and belief that this report is correct and complete and all outlays and unliquidated obligations are for the purposes set forth in the grant award documents.	
11.	Signature:			
12.	Printed name: 	     	
13.	Title: 	     	
14.	Date:	     	
15.	Phone: 	     	
Submit report to:	Chris Gukeisen, P.E.
South Dakota Energy Management Office
Joe Foss Building
523 E Capitol Avenue
Pierre, SD 57501-5981