Detailed Statement of Cost 10.20.22 (002) clean

U.S. DEPARTMENT OF LABOR

Detailed Statement of Costs

Grant Recipient Name and Address Grant Number

Cost Category	Approved Grant Budget	Actual Cumulative Costs
1. Salaries and Wages
2. Fringe Benefits
Total Personnel Costs
Other Expenses
3. Travel
4. Equipment
5. Supplies
6. Contractual
7. Other
8. Indirect Cost
Total Other Expenses
Total Grant Costs

Remarks

Certified by:

Authorized Representative Date

O M B No.: 1205-0NEW      O M B Expiration Date: xx/xx/xxxx     O M B Burden Hours: .25 minutes

Paperwork Reduction Act Statement: These reporting instructions have been approved under the Paperwork reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a valid OMB control number. Public reporting burden for this collection of information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Submission is mandatory under SSA 303(a)(6). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Grants Management, Room N.4716, 200 Constitution Ave., NW, Washington, DC, 20210.