Form 1 SSBG Reporting Form

APPENDIX A. SSBG REPORTING FORM

Part A. Expenditures and Provision Method					OMB NO.: 0970-0234
					EXPIRATION DATE: 07/31/2011
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.: 0970-0234
					EXPIRATION DATE: 07/31/2011
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