1 SSBG Post-Expenditure Reporting Form

The Paperwork Reduction Act of 1995 (Pub. L. 104-13). STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is identifying plans for state use of Social Services Block Grant (SSBG) Funding.

The purpose of this information is to identify estimated SSBG expenditures and recipients, as well as the intended geographic location and eligibility considerations for planned services. Information will be used to gain insight on the administration of the SSBG program and to provide support to grantees related to the administration of their SSBG program.

Public reporting burden for this collection of information is estimated to average 40 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information and is required to retain a benefit [45 C.F.R. §96.74.]. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0234 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact the Office of Community Services, Social Services Block Grant Program via email: [email protected] .

Overview. States must use this form as the reporting instrument to satisfy the requirements of 45 CFR 96.74.

States are to report on their expenditures for and recipients of services within 29 service areas that are defined in the Uniform Definitions of Services (https://www.acf.hhs.gov/ocs/resource/uniform-definition-of-services ). If the State’s definition of a service differs from the Uniform Definitions, the State should provide the State’s definition on the Intended Use Plan.

Fields requesting funding amounts are formatted for numbers only, and will not accept alphabetical text.

1. General Information

1. State – Enter the State the reporting form is being submitted for.

2. Fiscal Year – Enter the fiscal year the report is being submitted for.

3. State Official Contact Information – Enter the name, title, agency, phone number, and email address for the commissioner or director of the state’s lead SSBG agency.

4. SSBG Contact Information – Enter the name, title, agency, phone number, and email address for the state’s chief administrator of the SSBG.

5. SSBG Award from Previous Year – Enter the total amount of the SSBG award from the previous reporting period. Do not include amounts transferred or consolidated from other grant programs.

6. SSBG Expenditures Planned for Current Year – Enter the total SSBG expenditures estimated for the reporting period. Do not include SSBG funding that is being carried over from the previous year. Do not include funds that will be consolidated, or transferred from other grant programs.

7. TANF Funds Transferred into SSBG – Enter the total amount of funding transferred into SSBG from Temporary Assistance for Needy Families program (TANF). Do not include TANF Transfer Funding that is being carried over from a previous year.

8. Consolidated Block Grant Funds Included in SSBG Budget– Enter the total amount of funding added to SSBG from the Consolidated Block Grant.

   1. Funding Source(s) for the Consolidated Block Grant – Identify each funding source(s) for the Consolidated Block Grant.

   2. Amount of Funding from Each Program – Enter the amount of funding that relates to each program being consolidated.

9. SSBG Carryover Funding from the Previous Year – Enter yes if the State has unobligated funding from the previous year’s SSBG budget. Include TANF Transfer and amounts from the Consolidated Block Grant.

   1. Source(s) of Carryover Funding – Enter the program(s) that initially awarded the funds that are being carried over from the previous fiscal year (ex. SSBG, TANF, Consolidated Block Grant).

   2. Amount of Carryover from Each Source – Enter the amount of carryover funding from the previous fiscal year that relates to each program identified to have carryover funding.

2. Administrative Operations

1. Administering Agency – Identify the agency designated to administer the state’s SSBG program.

2. Location – Identify the address of the agency designated to administer the state’s SSBG program.

3. Mission/Goals of Agency – Outline the mission, goals and objectives, of the agency designated to administer the state’s SSBG program.

4. Description of Financial Operations Systems – Describe the state’s process for calculating and assigning costs (e.g., cost allocation plan). Describe the method of tracking and reconciling expenditures.

3. Program Planning

1. Planning for Distribution and Use of Funds – Describe the planning process for determining the state’s use and distribution of SSBG funds.

2. Describe the Characteristics of Individuals to be Served. Include definitions for child, adult, and family; eligibility criteria; and income guidelines.

3. Public Inspection of Pre-Expenditure Report – Describe and provide documentation on how the state made available for public inspection and comment the current Pre-Expenditure Report or revision to the report. States are encouraged to use the form for the Post-Expenditure Report (OMB # 0970-0234) to complete the Pre-Expenditure Report.

4. Program Operations

Complete one chart for each service category provided by the state during the reporting period.

1. Service Category (use uniform definition) – Enter the service supported with SSBG expenditure using SSBG’s Uniform Definition of Services. (https://www.acf.hhs.gov/ocs/resource/uniform-definition-of-services). In cases where no fit is possible between the state-defined services and the Uniform Definitions of Services, use item 29 “Other Services”.

2. SSBG Goal – Enter the SSBG goal that aligns with the service category.

3. Description of Services – Describe the services and activities to be provided using SSBG funds under this service category.

4. Description of Recipients (eligibility considerations) – If applicable, describe the eligibility criteria required for recipients to receive services under this category. Include income guidelines, age, geographic boundaries, etc.

5. Method of Delivery and Geographic Area – Identify the geographic area/location where services will be provided. Location should include the following information, when available: address, Census block, Census Tract, Zip code, and county.

6. Partnering State Agency – Identify the state entities that are allocated SSBG funds to provide services under the identified service category.

7. Sub Grantee/ Service Providers – When available, identify sub grantees and service providers that are allocated SSBG funds to provide services under the identified service category. Include the address for each entity identified.

V. Appendices

Appendix A: Documentation of Public Hearing

Attach documentation of public hearing, such as public hearing notices, websites, electronic correspondence, letters, newspaper articles, etc.

Appendix B: Certifications

Attach signed copies of the following certifications

1. Drug-Free Workplace Requirements

2. Environmental Tobacco Smoke

3. Lobbying

4. Debarment, Suspension and Other Responsibility Matters

Appendix C: Proof of Audit

Federal regulations state that: “Each State shall, not less often than every two years, audit its expenditures from amounts received (or transferred for use) under this title…Within 30 days following the completion of each audit, the State shall submit a copy of that audit to the legislature of the State and to the Secretary.” (Sec. 2006 [42 U.S.C. 1397a, Sec. 2006]). Provide a copy or link to the most recent audit, or a description of the audit that specifies when the audit occurred and summarizes the results of the audit.

Appendix D: SF 424M (Scanned copy must be uploaded with application)

Appendix E: Federal Financial Report (FFR) Form SF-425 (Scanned copy must be uploaded with the Intended Use Plan)