Form No. 1 No. 1 Data collection form

FINANCIAL STATUS REPORT

AOA SUPPLEMENTAL FORM TO SF-269-TITLE III

STATE______________ FY__________________

DATE SUBMITTED_____________________ REPORTING PERIOD ENDED________________

Item 10 i Column III, Total Recipient Share of Outlays which consist of outlays from:

State Non-State

ADMIN $_________________________ $________________________

Title III

Part B (Excluding LTCO Funds) $_________________________ $________________________

LTCO (Part B) Only $_________________________ $________________________

Part C-1 $_________________________ $________________________

Part C-2 $_________________________ $________________________

Part E (Including Grandparent Funds) $_________________________ $________________________

Grandparent Only $_________________________ $________________________

TOTAL $_________________________ $________________________

Item 10 j Column III, Federal Share of Net Outlays:

State Non-State

ADMIN $_________________________ $________________________

Title III

Part B (Excluding LTCO Funds) $_________________________ $________________________

LTCO (Part B) Only $_________________________ $________________________

Part C-1 $_________________________ $________________________

Part C-2 $_________________________ $________________________

Part E (Including Grandparent Funds) $_________________________ $________________________

Grandparent Only $_________________________ $________________________

TOTAL $_________________________ $________________________

Item 10 o Column III Total Federal Funds Authorized by AOA for the Federal FY__________ have been allocated by the State as follows (as applicable):

1. State administrative activities which consist of funds in the amount of $________________ from the following:

Part B $_______________________

Part C-1 $_______________________

Part C-2 $_______________________

Part D $_______________________

Part E $_______________________

2. Part B, Supportive Services (Including LTCO Funds) $____________________

3. Part B, Long Term Care Ombudsman Only $____________________ FY2000_______________

4. Part C-1, Congregate Meals $____________________

5. Part C-2, Home Delivered Meals $____________________

6. Part D, Preventive Health $____________________

7. Part E, Caregivers $____________________

Area Plan Administration $____________________

which consists of funds from:

Part B $____________________

Part C-1 $____________________

Part C-2 $____________________

Part E $____________________

Item 10 p Column III, Unobligated Funds:

Part B $____________________ Part D $____________________

Part C-1 $____________________ Part E $____________________

Part C-2 $____________________

Item 10 r Column III, Disbursed Program Income using the additional alternative (cumulative amount):

Part B $____________________ Part D $____________________

Part C-1 $____________________ Part E $____________________

Part C-2 $____________________