Form 1 Postexpenditure Report

SSBG REPORTING FORM

Part A. Expenditures and Provision Method

OMB NO.:

EXPIRATION DATE:

STATE:

FISCAL YEAR:

REPORT PERIOD:

Contact Person:

Phone Number:

Title:

E-Mail Address:

Agency:

Submission Date:

Service Supported with SSBG Expenditures

SSBG Expenditures

Expenditures of All Other Federal, State and Local funds**

Total Expenditures

Provision Method

SSBG Allocation

Funds transferred into SSBG*

Public

Private

1

Adoption Services

2

Case Management

3

Congregate Meals

4

Counseling Services

5

Day Care—Adults

6

Day Care—Children

7

Education and Training Services

8

Employment Services

9

Family Planning Services

10

Foster Care Services—Adults

11

Foster Care Services—Children

12

Health-Related Services

13

Home-Based Services

14

Home-Delivered Meals

15

Housing Services

16

Independent/Transitional Living Services

17

Information & Referral

18

Legal Services

19

Pregnancy & Parenting

20

Prevention & Intervention

21

Protective Services—Adults

22

Protective Services—Children

23

Recreation Services

24

Residential Treatment

25

Special Services—Disabled

26

Special Services--Youth at Risk

27

Substance Abuse Services

28

Transportation

29

Other Services***

30

SUM OF EXPENDITURES FOR SERVICES

31

Administrative Costs

32

SUM OF EXPENDITURES FOR SERVICES AND ADMINISTRATIVE COSTS

* From which block grant(s) were these funds transferred?

** Please list the sources of these funds:

*** Please list other services:

Part B. Recipients

OMB NO.:

EXPIRATION DATE:

STATE:

FISCAL YEAR:

Service Supported with SSBG Expenditures

Children

Adults

Total Adults

Total

Adults Age 59 Years & Younger

Adults Age 60 Years & Older

Adults of Unknown Age

1

Adoption Services

2

Case Management

3

Congregate Meals

4

Counseling Services

5

Day Care--Adults

6

Day Care--Children

7

Education and Training Services

8

Employment Services

9

Family Planning Services

10

Foster Care Services--Adults

11

Foster Care Services--Children

12

Health-Related Services

13

Home-Based Services

14

Home-Delivered Meals

15

Housing Services

16

Independent/Transitional Living Services

17

Information & Referral

18

Legal Services

19

Pregnancy & Parenting

20

Prevention & Intervention

21

Protective Services--Adults

22

Protective Services--Children

23

Recreation Services

24

Residential Treatment

25

Special Services--Disabled

26

Special Services--Youth at Risk

27

Substance Abuse Services

28

Transportation

29

Other Services

30

SUM OF RECIPIENTS OF SERVICES