U.S. DEPARTMENT OF THE INTERIOR OMB Control No. 1029-0059
Office of S urface Mining Reclamation and Enforcement
Exp. Date: 7/31/2021
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A. Program E. Budget Period (Month, Day, Year) F. Mark 'X' in Appropriate Box
B. Grantee Beginning Date ( ) New Budget
C. Grant Program Ending Date ( ) Revised Budget (Enter Grant Number)
D. Rate of Federal Sharing (%) ( ) Grant Number
TOTAL
(a) (b) ( c ) (d) (e) (f) (g)
1. Personnel
2. Fringe Benefit
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2EMHFW&ODVV 5. Supplies
6. Contractural
7. Construction
8. Other
9. Total Direct Charges
10. Indirect Charges
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6RXUFH 13. Federal Share
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,QFR PH 14. Program Income
6HFWLRQ' 15. Detail on Indirect Cost ( ) Predetermined ( ) Provisional ( ) Final ( ) Fixed
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LUHFW Type of Rate (mark 'X' in Box) Total Amount _______________ Base _________
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E. Signature of Authorizing Official F. Name and Title (type or print) G. Telephone Number (Area Code, Number H. Date Report Submitted
and Extension)
Excel OSM-47 (8/97)
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signature
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