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Financial Report Submission

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Use this online form to complete your financial report disclosure information. This session will be active for a total of one hour in order to allow you to complete this form. If your session is disconnected or the form is not completed within one hour, you will need to begin the form again.
Once the online form is complete select the �Submit to Society� link to submit this form to the Society. The Society will then email a copy of your submission as a PDF file to the email address specified in the preparer (Certifying Official) information section of the form.
Once the Certifying Official receives the email, they should print and sign the completed form.
Mail the completed and signed form to the Director of Research Administration at the address specified on the Grant Reporting and Requests page.

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Financial Report Profile - Grantee Information

Society Grant #:	(Ex. R6215-02 or 6543-05)

Grant Recipient:

Reporting Period (e.g. 10/01/2002)		To:
Grant Period (e.g. 10/01/2002)		To:

Report Type:

Interim Report

Final Report

Revised Report/Number

	Current Period	Cumulative to Date
1. Cash Received for Direct Costs
2. Cash Received for Indirect Costs
3. Total Cash Received (Line 1 + 2)
4. Direct Costs
A. Salaries and Wages
B. Fringe Benefit Expenses
C. Supplies and Materials
D. Equipment
E. Travel
F. Other Direct Costs
G. Total Direct Costs (Line 4A thru 4F)
5. Indirect Costs
6. Total Direct and Indirect Costs (Line 4G + 5)
7. Cash Balance (Line 3 - Line 6)

A positive balance on line 7 indicates that expenses incurred are less than the awarded amount and these funds must be returned to the Leukemia Lymphoma Society upon completion or termination of the grant.

A negative balance on line 7 indicates that expenses incurred exceed the awarded amount. Expenses in excess of the awarded amounts are not reimbursed by the Society.

Add any comments related to the financial report

Preparer Information (Certifying Official)

By checking the preceding check box and submitting this report to the Society. I certify that I am authorized to submit and I fully understand the information disclosed in this report.

First & Last Name:
Institution:
Street Address and Secondary Address Information if necessary

	City	State	Zip Code

Country

Telephone:		Ext:
Fax:
Email:

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last updated on 06/24/03

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