Certification of Maintenance of Effort

OMB # 0985-0009
exp. 11/30/2020
Instructions for Completing the Certification of Long-Term Care Ombudsman Program Expenditures

FFY2019 Base Year Reporting
States are to report base year Federal Fiscal Year (FFY) 2019 expenditures (10/1/2018-9/30/2019)
Expenditures means charges made by a non-Federal entity to a project or program for which a Federal
award was received.1

Expenditures of the following funds are subject to minimum funding requirements in the Older Americans
Act (2020 Authorization). FY ______ expenditures must have met or exceeded these amounts.

Title VII, Chapter 2, Ombudsman
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Report the amount that was EXPENDED on the Long Term Care Ombudsman program by the
State, Local, Subgrantees, and/or Contractors of funds received under Title VII, Chapter 2 Long
Term Care Ombudsman for the period 10/1/2018-9/30/2019
Do not include other cash or in-kind contributions or match
Do not include program income
Note: all Title VII, Chapter 2, Ombudsman funds must be expended on the Long Term Care
Ombudsman program

Title VII, Chapter 3, Abuse Prev.
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Report the amount that was EXPENDED on the Long Term Care Ombudsman program by the
State, Local, Subgrantees, and/or Contractors of funds received under Title VII Chapter 3, Elder
Abuse and Prevention for the period 10/1/2018-9/30/2019
Do not include other cash or in-kind contributions or match
Do not include program income

1

Title 45: PUBLIC WELFARE PART 75—UNIFORM ADMINISTRATIVE REQUIREMENTS, COST PRINCIPLES, AND AUDIT
REQUIREMENTS FOR HHS AWARDS

1
Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
such collection displays a valid OMB control number (OMB 0985-0009). Public reporting burden for this collection of
information is estimated to average 30 minutes per response, including time for gathering and maintaining the data needed
and completing and reviewing the collection of information.

OMB # 0985-0009
exp. 11/30/2020
Title III, expended by State, as authorized in OAA, Sec.304(d)(1)(B)


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Report the amount EXPENDED on the Long Term Care Ombudsman program by the State,
Subgrantees, and/or Contractors other than AAAs and/or funds passed through to the AAAs of
funds received under Title III Part B for the period 10/1/2018-9/30/2019
Do not include other cash or in-kind contributions or match
Do not include program income

Title III provided at AAA level
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Report the amount EXPENDED on the Long Term Care Ombudsman program by all Area Agencies
on Aging within the State of funds received under Title III Part B for the period 10/1/20189/30/2019
Do not include cash or in-kind contributions or match
Do not include program income
Note: the State should ensure, through the Area Plan and/or other processes, that AAAs are
meeting the previous minimum funding level

Report other sources of funds expended, minimum funding does not apply
Other Federal
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Report the amount EXPENDED on the Long Term Care Ombudsman program by State, Area
Agencies on Aging, Local, Subgrantees, and/or Contractors from other federal funds for the
period 10/1/2018-9/30/2019 including, but not limited to Medicaid, Social Services Block Grant,
Community Development Block Grant, etc.
Include all Other Federal sources of cash match or contributions
Do not include non-Federal expenditures such as State/Local cash, in-kind contributions, and/or
match
Do not include program income

State funds


Report the amount EXPENDED by State, Area Agencies on Aging, Subgrantees and/or Contractors
on the Long Term Care Ombudsman program with State funds for the period 10/1/2018-9/30/2019
2

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
such collection displays a valid OMB control number (OMB 0985-0009). Public reporting burden for this collection of
information is estimated to average 30 minutes per response, including time for gathering and maintaining the data needed
and completing and reviewing the collection of information.

OMB # 0985-0009
exp. 11/30/2020

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including, but not limited to; State General Revenue Funds, State Revolving Funds, State Dedicated
Funds, State fee or tax, Civil Monetary Penalties, etc.
Include all State sources of cash contributions and/or cash match
Do not include in-kind contributions or in-kind match
Do not include program income

Local funds


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


Report the amount EXPENDED by Area Agencies on Aging and their Subgrantees and/or
Contractors on the Long Term Care Ombudsman program with Local funds for the period
10/1/2018-9/30/2019 including, but not limited to; Local General Revenue Funds, Local Revolving
Funds, Local Dedicated Funds, private grants, Fundraising Revenues, etc.
Include all Local sources of cash contributions and/or cash match
Do not include in-kind contributions or in-kind match
Do not include program income

Future Certifications
Each year ACL will notify the State Unit on Aging (SUA) Director requesting certification of expenditures.
Please send the signed certification for the preceding fiscal year expenditures as indicated in the
notification.

3
Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
such collection displays a valid OMB control number (OMB 0985-0009). Public reporting burden for this collection of
information is estimated to average 30 minutes per response, including time for gathering and maintaining the data needed
and completing and reviewing the collection of information.