Supplemental Form to the Financial Status Report for all AoA Title III Grantees

Forms and Documents

Document Name	Status
0004 Supporting Statement Title III Supplement (SF-425) 112020.docx Supporting Statement A	2020-11-27
269_Supplemental_Form_Instructions_to_OMB[1].doc Supplementary Document	2007-08-29

IC Document Collections

IC ID	Document Title	Status
10243	Supplemental Form-Financial Status for ACL Title III Grants Instruction	Modified

ICR Details

OMB Control No: 0985-0004	ICR Reference No: 202010-0985-001
Status: Active	Previous ICR Reference No: 201710-0985-002
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: Supplemental Form to the Financial Status Report for all AoA Title III Grantees
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/04/2021
	Date Received in OIRA: 11/30/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2024	36 Months From Approved	12/31/2020
Responses	112	0	112
Time Burden (Hours)	224	0	224
Cost Burden (Dollars)	0	0	0

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Abstract: The Administration for Community Living (ACL) requires grantees funded under the Older Americans Act, P.L. 116-131, to report semi-annually on the financial status report of the performance of their projects. The specifications for reporting are consistent with 45CFR75.342(b)(1). The financial report is submitted on standard form 425. The Title III Supplemental Form to the Financial Status Report (SF-425) is used by ACL/AoA for all grantees to obtain a more detailed understanding of how projects funded under Title III of the Older Americans Act (OAA) of 1965, as amended, are being administered, and to ensure compliance with legislative requirements, pertinent Federal regulations and other applicable instructions and guidelines issued by the ACL. The level of data detail necessary is not available through the Federal Financial Status Report (SF-425) form. The Title III Supplemental Form provides necessary details on non-federal required match and expenditures for services, administration, and Long Term Care Ombudsman expenditures.

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Authorizing Statute(s): US Code: 42 USC 3021 Name of Law: Programs for Older Americans
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 51033	08/19/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 73274	11/17/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Supplemental Form-Financial Status for ACL Title III Grants	ACL SF-425 T-3	Supplemental Form-Financial Status for ACL Title III Grants

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	112	112	0	0	0	0
Annual Time Burden (Hours)	224	224	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $13,959

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/30/2020

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