New Jersey Department of Health

STATEMENT OF PROGRAM INCOME

Name of Grantee

Address

Grant Number

Budget Period

From:

to:
INSTRUCTIONS: This statement shall be completed, signed and returned by the grantee at the time the final Report of Grant Expenditures is prepared. The form shall be completed on a cash basis. If no income has been received, indicate this on the form. This statement is due within sixty (60) days after the termination date of the Grant and should accompany the Report of Grant Expenditures. If you have any questions concerning the completion of this form, please contact the Grant Management Officer assigned responsibility for this Grant.
SECTION A – TO BE COMPLETED BY THE GRANTEE
1.	Balance of Program Income – Beginning of Budget Period	$
2.	Program Income collected during this Budget Period	$
3.	Total Program Income (Item 1 plus Item 2)	$
4.	Expenditure of Program Income during Budget Period	$
5.	Balance of Program Income – End of Budget Period (Item 3 less Item 4)	$
Signature of Grantee	Date
SECTION B – NJDOH STAFF USE
1. Treatment of Program Income as allowed in Attachment B of the grant
Deduction Alternative	Cost-Sharing or Matching Alternative
Added to the grant funds to further eligible program objectives
Other (Describe):
2. Balance of Program Income (from Section A.5) at the end of Budget Period	$
3. Final Disposition
a. Carried forward and approved in new Grant Award	$
b. Balance to be returned	$
Signature of Grant Management Officer	Date
FS-63

AUG 12

FS-63 Statement of Program Income

Elaine White

2003-01-30

ewhite

NJDOH