quarterly report for bond proceeds - dfa.ms.gov · state of mississippi. governor phil bryant ....
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STATE OF MISSISSIPPI GOVERNOR PHIL BRYANT
DEPARTMENT OF FINANCE AND ADMINISTRATION LAURA D. JACKSON
EXECUTIVE DIRECTOR
Quarterly Report for Bond Proceeds
Name of Entity: _______________________________________________________________________________________________
Project Description: __________________________________________________________________________________________
Authorizing Legislation: _____________________________________________________________________________________
Report for the Quarter Ending: March 31 September 30 For the Year: _________________
June 30 December 31
Report Type: Initial Quarterly Final
Please complete only upon initial receipt of funding
Initial Receipt of Bond Proceeds (__________________): $_________________________________
Less: Pro Rata Share of Issuance Cost (if applicable): ($________________________________)
Beginning Project Balance: $_________________________________
Beginning Quarterly Balance (__________________): $__________________________________
Less: Quarterly Project Expenditures: ($________________________________)
Ending Quarterly Balance (__________________): $__________________________________
Project Update Summary (please supply a quarterly update regarding status of project):
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Revised August 2017
I, the undersigned authority, do hereby swear and affirm that all information provided above is
complete and accurate to the best of my knowledge. I further swear and affirm that all State bond
proceeds reported on herein were used in accordance with the legislation that authorized such bonds.
Authorized by:
________________________________________________________ Name
________________________________________________________ Signature
________________________________________________________ Title
________________________________________________________ Date
Sworn to and subscribed before me this ________________day of______________________, 20______
State of MississippiCounty of: _____________________________
Notary Public _________________________________________________________My Commission Expires _____________________________________________
Notary Public
Seal
Revised August 2017