Block Grant Application

Community MH Services BG and SAPT BG Application Guidance and Instructions FY 2019-2021

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0168 can be found here:

Documents and Forms

Document Name Document Type
Form BG Application Block Grant Application Form and Instruction
BG Application BG Application 04.17.2019 FFY 2020-2021 Block Grant Application and Plan CLEAN.docx Form and Instruction
BG Application BG Application 04.17.2019 FFY 2020-2021 Block Grant Application and Plan CLEAN.docx Form and Instruction
FFY 2020-2021 MHBG Report.pdf MH BG Report IC Document
FFY 2020-2021 MHBG Report.pdf MH BG Report IC Document
FY 2020-2021SABG Report.pdf SA BG Report IC Document
FY 2020-2021SABG Report.pdf SA BG Report IC Document
FY20-21 MHBG-funding-agreements.pdf MH BG Funding Agreements IC Document
FY20-21 MHBG-funding-agreements.pdf MH BG Funding Agreements IC Document
FY20-21 SABG-funding-agreements.pdf SA BG Funding Agreements IC Document
FY20-21 SABG-funding-agreements.pdf SA BG Funding Agreements IC Document

Information Collection (IC) Details

IC Title:	Block Grant Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	BG Application	BG Application	04.17.2019 FFY 2020-2021 Block Grant Application and Plan CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 119	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	119	119
Annual IC Time Burden (Hours)	33,374	33,374
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
MH BG Report	FFY 2020-2021 MHBG Report.pdf	01/08/2019
SA BG Report	FY 2020-2021SABG Report.pdf	01/08/2019
MH BG Funding Agreements	FY20-21 MHBG-funding-agreements.pdf	01/08/2019
SA BG Funding Agreements	FY20-21 SABG-funding-agreements.pdf	01/08/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.