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pdfOMB #0970-0234
Exp. Date:
Division of Social Services
Social Services Block Grant
Intended Use Plan
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 Bock 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
. 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].
I. General Information
1. State Select One.
3. State Official Contact Information
2. Fiscal Year Select One.
4. SSBG Contact Information
5. SSBG Award from Previous Year
6. SSBG Expenditures Planned for Current Year
7. TANF Funds Transferred into SSBG
8. Consolidate Block Grant Funds Included in SSBG Budget: YES
NO
Provide the amount of funding for each applicable funding source for the consolidated block
grant.
a. Funding Source(s) for the Consolidated Block
b. Amount of Funding from Each
Grant
Program
9. SSBG Carryover Funding from the Previous Year: YES
a. Source(s) of Carryover Funding
NO
b. Amount of Carryover from Each
Source
II. Administrative Operations
1. Administering Agency
2. Location
3. Mission/Goals of Agency
4. Description of Financial Operations Systems
III. 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 how the State made available for public inspection and comment the current PreExpenditure Report or revision to the report. Supporting documentation for public inspection is
also required. (See V. Appendices, Appendix A: Documentation of public Hearing).
IV. Program Operations
Complete one table for each service category provided by the state during the reporting period.
1. Program Operations – Adoption Services
a. Service Category (use uniform definition) – Adoption Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
2. Program Operations – Case Management Services
a. Service Category (use uniform definition) – Case Management Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
3. Program Operations – Congregate Meals
a. Service Category (use uniform definition) – Congregate Meals
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
4. Program Operations – Counseling Services
a. Service Category (use uniform definition) – Counseling Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
5. Program Operations – Day Care Services – Adults
a. Service Category (use uniform definition) – Day Care Services – Adults
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
6. Program Operations – Day Care Services – Children
a. Service Category (use uniform definition) – Day Care Services – Children
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
7. Program Operations – Education and Training Services
a. Service Category (use uniform definition) – Education and Training Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
8. Program Operations – Employment Services
a. Service Category (use uniform definition) – Employment Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
9. Program Operations – Family Planning Services
a. Service Category (use uniform definition) – Family Planning Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
10. Program Operations – Foster Care Services for Adults
a. Service Category (use uniform definition) – Foster Care Services for Adults
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
11. Program Operations – Foster Care Services for Children
a. Service Category (use uniform definition) – Prevention and Intervention Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
12. Program Operations – Health Related and Home Health Services
a. Service Category (use uniform definition) – Health Related and Home Health Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
13. Program Operations – Home Based Services
a. Service Category (use uniform definition) – Home Based Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
14. Program Operations – Home Delivered Meals
a. Service Category (use uniform definition) – Home Delivered Meals
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
15. Program Operations – Housing Services
a. Service Category (use uniform definition) – Housing Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
16. Program Operations – Independent and Transitional Living Services
a. Service Category (use uniform definition) – Independent and Transitional Living Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
17. Program Operations – Information and Referral
a. Service Category (use uniform definition) – Information and Referral
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
18. Program Operations – Legal Services
a. Service Category (use uniform definition) – Legal Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
19. Program Operations – Pregnancy and Parenting Services for Young Parents
a. Service Category (use uniform definition) – Pregnancy and Parenting Services for Young
Parents
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
20. Program Operations – Prevention and Intervention Services
a. Service Category (use uniform definition) – Prevention and Intervention Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
21. Program Operations – Protective Services for Adults
a. Service Category (use uniform definition) – Protective Services for Adults
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
22. Program Operations – Protective Services for Children
a. Service Category (use uniform definition) – Protective Services for Children
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
23. Program Operations – Recreational Services
a. Service Category (use uniform definition) – Recreational Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
24. Program Operations – Residential Treatment Services
a. Service Category (use uniform definition) – Residential Treatment Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
25. Program Operations – Special Services for Persons with Developmental or Physical
a. Service Category (use uniform definition) – Special Services for Persons with
Developmental or Physical
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
26. Program Operations – Special Services for Youth Involved in or at Risk of Involvement with
Criminal Activity
a. Service Category (use uniform definition) – Special Services for Youth Involved in or at Risk
of Involvement with Criminal Activity
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
27. Program Operations – Substance Abuse Services
a. Service Category (use uniform definition) – Substance Abuse Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
28. Program Operations – Transportation Services
a. Service Category (use uniform definition) – Transportation Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
29. Program Operations – Other Services
a. Service Category (use uniform definition) – Other Services
b. SSBG Goal
c. Description of Services
d. Description of Recipients (eligibility considerations)
e. Method of Delivery and Geographic Area
f.
Partnering State Agency
g. Subgrantee / Service Providers
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) For SF-425 Federal Financial Reporting (FFR) Form SF-425
Scanned copy must be uploaded with the Intended Use Plan
| File Type | application/pdf |
| Author | Clark, Christina (ACF) |
| File Modified | 2021-02-12 |
| File Created | 2021-02-11 |