SF-425 ACL/AOA Title III Supplemental Form to SF-425

Federal Financial Report (FFR) ACL/AOA Title III Supplemental Form to SF-425

State
Federal Fiscal Year
Date Submitted
Reporting Period Ending

Item 10 d. Total Federal Funds Authorized

All Parts: Total State Plan Administration
All Parts: Total Area Plan Administration
Total Part B
Total Part C-1
Total Part C-2
Total Part D
Total Part E
Total All Parts

Item 10 e. Federal Share of Expenditures

Part and Description	State	Non-State
Part B Administration
Part B LTCO
Part B Supportive Services
Total Part B
Part C-1 Administration
Part C-1 Congregate Meals
Total Part C-1
Part C-2 Administration
Part C-2 Home Delivered Meals
Total Part C-2
Part D Administration
Part D Preventive Health
Total Part D
Part E Administration
Part E Older Relative Caregiver Only
Part E Caregiver Services

Total Part E
Total All Parts
Total Administration
Total B, C-1, C-2 Services

Item 10 i. Total Recipient Share Required

Part and Description	Match Percentage	Amount
Part B Administration	25%
Part B LTCO	0%
Part B Supportive Services	15%
Total Part B
Part C-1 Administration	25%
Part C-1 Congregate Meals	15%
Total Part C-1
Part C-2 Administration	25%
Part C-2 Home Delivered Meals	15%
Total Part C-2
Part D Administration	25%
Part D Preventive Health	0%
Total Part D
Part E Administration	25%
Part E Older Relative Caregiver Only	25%
Part E Caregiver Services	25%
Total Part E
Total All Parts

Item 10 j. Total Recipient Share of Expenditures

Part and Description	State	Non-State
Part B Administration
Part B LTCO
Part B Supportive Services
Total Part B
Part C-1 Administration
Part C-1 Congregate Meals
Total Part C-1
Part C-2 Administration

Part C-2 Home Delivered Meals
Total Part C-2
Part D Administration
Part D Preventive Health
Total Part D
Part E Administration
Part E Older Relative Caregiver Only
Part E Caregiver Services
Total Part E
Total All Parts
Total Administration
Total B, C-1, C-2 Services

Comments:

Paperwork Reduction Act Public Burden Statement

According to the Paperwork Reduction Act of 1995 5 CFR § 1320.8(b)(3), no persons are required to respond to a collection of information unless such collection displays a valid OMB control number (OMB 0985-008X). Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time for gathering, maintaining the data needed, completing, and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefits under the Older Americans Act (P.L. 116-131). Information collected is planned for use by ACL to conduct federal oversight of Aging Programs. ACL uses information collected to monitor federal funds. Data will be kept private to the extent allowed by law. There are no assurances of confidentiality. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Administration for Community Living, U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, Attention Adam Mosey [email protected] and reference the OMB Control Number 0985-xxxx. Note: Please do not return the completed information collection to this address.

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