State of Tennessee

Income Summary Report

All income generated as a direct result of the grant shall be deemed program income. Fines are not counted as income.

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Program Manager*

Project Title*

Grant Number*

Agency Name*

Person Completing Report

First Name

Last Name

Phone Number

Email Address

Confirm Email Address *

Fund Source*

Does your program have income to report?

Yes No

Fiscal Year

Is this a Quarterly or an Annual Summary?

What Fiscal Year?

What is the last month of the quarter you are reporting on?

Accumulated Previously this FY

Accumulated this Quarter

Total Accumulation

Forfeited Funds (Cash Only)

Forfeited Property

Other Program Income

Total Program Income

What is your total approved operating budget for the current fiscal year?

NOTE: If your agency utilizes non-grant funds to support its operations those funds should be included in this total.

What is the total amount of GRANT FUNDS approved for the current fiscal year?

NOTE: This is grant funds only and does not include match.

Effective Program Income Percentage (Grant Contract/Total Budget):

Effective Program Income (EPI % * Total Program Income)

Financial Officer's Name*

First Name

Last Name

Email of Financial Officer*

Confirm Email of Financial Officer *

Project Director's Name*

First Name

Last Name

Email of Project Director*

Confirm Email of Project Director *