State __________ Number __________ Date __________ State Official Authorized Signature: Name: Title: Date: Federal Official Authorized Signature: NHTSA Name: Title: Date:

Effective Date: This form is to be used to provide funding documentation for grant programs under Title 23, United States Code. A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is ______________. Public reporting for this collection of information is estimated to be approximately 30 minutes per response, including the time for reviewing instructions and completing the form. All responses to this collection of information are required to obtain or retain benefits. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Avenue SE., Washington DC 20590.

INSTRUCTIONS FOR PROGRAM COST SUMMARY

State—The State submitting the HS Form-217

Number—Each HS-217 will be in sequential order by fiscal year (e.g., 99-01, 99-02, etc.)

Date—The date of occurrence of the accounting action(s) described.

Program Area—The code designating a program area (e.g., PT-99, where PT represents the Police Traffic Services and 99 represents the Federal fiscal year). Funds should be entered only at the program area level, not at the task level or lower.

Approved Program Costs—The current balance of Federal funds approved (but not obligated) under the HSP or under any portion of or amendment to the HSP.

State/local Funds—Those funds which the State and its political subdivisions are contributing to the program, including both hard and soft match.

Previous Balance—The balance of Federal funds obligated and available for expenditure by the State in the current fiscal year, as of the last Federally-approved transaction. The total of this column may not exceed the sum of the State's current year obligation limitation and prior year funds carried forward. (The column is left blank on the updated Cost Summary required to be submitted under 23 CFR 1200.11(e). For subsequent submissions, the amounts in this column are obtained from the “Current Balance” column of the immediately preceding Cost Summary.)

Increase/(Decrease)—The amount of change in Federal funding, by program area, from the funding reflected under the “Previous Balance”.

Current Balance—The net total of the “Previous Balance” and the “Increase/(Decrease)” amounts. The total of this column may not exceed the sum of the State's current year obligation limitation and prior year funds carried forward.