SSBG REPORTING FORM
Part A. Expenditures and Provision Method |
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OMB NO.: |
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EXPIRATION DATE: |
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STATE: |
FISCAL YEAR: |
REPORT PERIOD: |
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Contact Person: |
Phone Number: |
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Title: |
E-Mail Address: |
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Agency: |
Submission Date: |
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Service Supported with SSBG Expenditures |
SSBG Expenditures |
Expenditures of All Other Federal, State and Local funds** |
Total Expenditures |
Provision Method |
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SSBG Allocation |
Funds transferred into SSBG* |
Public |
Private |
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1 |
Adoption Services |
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2 |
Case Management |
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3 |
Congregate Meals |
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4 |
Counseling Services |
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5 |
Day Care—Adults |
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6 |
Day Care—Children |
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7 |
Education and Training Services |
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8 |
Employment Services |
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9 |
Family Planning Services |
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10 |
Foster Care Services—Adults |
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11 |
Foster Care Services—Children |
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12 |
Health-Related Services |
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13 |
Home-Based Services |
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14 |
Home-Delivered Meals |
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15 |
Housing Services |
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16 |
Independent/Transitional Living Services |
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17 |
Information & Referral |
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18 |
Legal Services |
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19 |
Pregnancy & Parenting |
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20 |
Prevention & Intervention |
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21 |
Protective Services—Adults |
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22 |
Protective Services—Children |
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23 |
Recreation Services |
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24 |
Residential Treatment |
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25 |
Special Services—Disabled |
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26 |
Special Services--Youth at Risk |
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27 |
Substance Abuse Services |
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28 |
Transportation |
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29 |
Other Services*** |
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30 |
SUM OF EXPENDITURES FOR SERVICES |
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31 |
Administrative Costs |
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32 |
SUM OF EXPENDITURES FOR SERVICES AND ADMINISTRATIVE COSTS |
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* From which block grant(s) were these funds transferred? |
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** Please list the sources of these funds: |
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*** Please list other services: |
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Part B. Recipients |
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OMB NO.: |
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EXPIRATION DATE: |
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STATE: |
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FISCAL YEAR: |
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Service Supported with SSBG Expenditures |
Children |
Adults |
Total Adults |
Total |
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Adults Age 59 Years & Younger |
Adults Age 60 Years & Older |
Adults of Unknown Age |
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1 |
Adoption Services |
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2 |
Case Management |
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3 |
Congregate Meals |
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4 |
Counseling Services |
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5 |
Day Care--Adults |
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6 |
Day Care--Children |
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7 |
Education and Training Services |
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8 |
Employment Services |
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9 |
Family Planning Services |
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10 |
Foster Care Services--Adults |
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11 |
Foster Care Services--Children |
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12 |
Health-Related Services |
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13 |
Home-Based Services |
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14 |
Home-Delivered Meals |
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15 |
Housing Services |
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16 |
Independent/Transitional Living Services |
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17 |
Information & Referral |
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18 |
Legal Services |
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19 |
Pregnancy & Parenting |
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20 |
Prevention & Intervention |
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21 |
Protective Services--Adults |
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22 |
Protective Services--Children |
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23 |
Recreation Services |
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24 |
Residential Treatment |
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25 |
Special Services--Disabled |
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26 |
Special Services--Youth at Risk |
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27 |
Substance Abuse Services |
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28 |
Transportation |
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29 |
Other Services |
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30 |
SUM OF RECIPIENTS OF SERVICES |
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File Type | application/msword |
File Title | SSBG REPORTING FORM |
Author | Liz Oppenheim |
Last Modified By | mwerner |
File Modified | 2007-10-02 |
File Created | 2007-10-02 |