Completion Report

Grantee Name:
Grantee Address:
(Number and Street)
(City, State, Zip Code)
Activity Title:
Award #:	Completion Date:
Program Year:	Matrix Code:	20A – State Planning-Only Activities

I certify to the best of my knowledge and belief that the information provided herein is true, complete, and accurate. I am aware that the provision of false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil, or administrative consequences including, but not limited to violations of U.S. Code Title 18, Sections 2, 1001, 1343 and Title 31, Sections 3729-3730 and 3801-3812.

Date:
Name and Title of Official Authorized in the Resolution
Signature of Official Authorized in the Resolution

Instructions: Select the appropriate Accomplishment type and National Objective from the dropdown menus below. Accomplishment: Click anywhere in the orange ‘Choose an Accomplishment’ text. Once you see the upside-down triangle (), select the appropriate accomplishment metric from the drop-down menu. National Objective: Click anywhere in the orange ‘select Award’s National Objective’ text. Once you see the below screenshot, click on the small menu icon as pictured below. Select the appropriate National Objective for this award.

Accomplishments

Accomplishment Narrative:

Number of Choose an Accomplishment.:

National Objective:

select Award’s National Objective