KATHRYN B. BREWER

Executive Coordinator

RYAN STEPHENSON

Assistant Executive Coordinator

STATE OF OKLAHOMA

DISTRICT ATTORNEYS COUNCIL

421 NW 13th Street, Suite 290 | OKC, OK, 73103

Federal Grants Division

Ph: 405-264-5008

Project Income Verification Form A-13

Subgrant/Activity No.

Organization:

Address:

City:

State: OK

Zip +4:

Project Director:

DO NOT SIGN PAGE 2 BEFORE READING THIS SECTION

Project Income: defined as any gross income earned as a direct result of grant supported activities or earned only as a result of the grant during the grant funding period.

Direct Result: defined as a specific act or set of activities that are directly attributable to grant funds, and which are directly related to the goals and objectives of the project.

Based on the definitions above, check the item below that applies to this grant award and sign only the corresponding section on page 2.

Check the item that applies to this grant

The subgrantee will be receiving income as direct result of program activities

The subgrantee will not be receiving income as a direct result of program activities

Section to Sign

ONLY complete Section 1 on page 2.

ONLY complete Section 2 on page 2.

Important:

Only sign the section that applies to this grant award.

All other sections should be left unsigned.

Section 1: Assurance Statement (WILL be receiving project income)

I, (authorizing official) assure that the funded entity will comply with the provisions on project income as set forth in the Financial and Administrative Guide. This Guide requires submission of quarterly project income reports.

Signature of Authorized Official

Date

Signature of Project Director

Date

Section 2: Assurance and Certification Statement (will NOT be receiving project income)

I, (authorizing official) assure that the funded entity will not be receiving any income as a direct result of the program activity. I further certify that if the entity begins to receive income as a direct result of the program activities, I will notify the Federal Grants Division Director, in writing, within 30 days of the receipt of the income.

Signature of Authorized Official

Date

Signature of Project Director

Date