Instructions

APPENDIX C. INSTRUCTIONS FOR SSBG REPORTING FORM¹

The Paperwork Reduction Act of 1995 (Pub. L. 104-13). Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. Respondents may direct comments concerning this estimate to: Office of Community Services, Administration for Children and Families, U. S. Department of Health and Human Services, 370 L’Enfant Promenade, SW, Washington, DC 20447.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Overview. States must use this form as the reporting instrument to satisfy the requirements of 45 CFR 96.74(a)(1) through (4).

States are to report on their expenditures for and recipients of services within 29 service areas that are defined in the Uniform Definitions of Services (see attached). If the State’s definition of a service differs from the Uniform Definitions, the State should clearly explain this in the pre-expenditure report.

State. Enter the name of the State submitting the form.

Fiscal Year. Enter the fiscal year for which the form is being submitted. States can report on either the State or Federal fiscal year. The report is due either 6 months after the end of the reporting period or at the time that the State submits the pre-expenditure report for the reporting period beginning after that 6-month period. For example, if the report covers the State fiscal year, which ends on June 30, 2004, the FY 2004 report must be submitted either on or before December 31, 2004 or with submission of the 2007 pre-expenditure report. If the report covers the Federal fiscal year, which ends on September 30, 2004, the FY 2004 report must be submitted either on or before March 31, 2005 or with submission of the 2007 pre-expenditure report.

Report Period. Enter the month and year of the beginning and end of the fiscal year—e.g., 07/04 to 06/05.

Contact Person. Enter the name of the contact person who can answer questions about the data.

Title. Enter the title for the contact person.

Agency. Enter the agency of the contact person.

Phone Number. Enter the telephone number of the contact person.

E-mail Address. Enter the e-mail address of the contact person.

Submission Date. Enter the date the report is being submitted.

Part A. Expenditures and Provision Method

States are required to submit expenditure data for each service that is supported in whole or in part by SSBG Expenditures. A State reports on the total of expended funds as of the close of the reporting year. This amount may include funds appropriated in previous years.

For each service that is supported with SSBG Expenditures in the State, States are to report on the Total Expenditures from all sources of funds for that service. A State reports the amount of SSBG Allocation, the amount of Funds Transferred into SSBG, and the combined amount of All Other Federal, State, and Local Funds spent for that service. By reporting on expenditures of all sources of funds for each service, States can provide an accurate picture of the role that SSBG Expenditures plays in supporting services.

Column: Service Supported with SSBG Expenditures. In cases where no fit is possible between the State-defined services and the Uniform Definitions of Services, use item 29, “other services.” Please sum all expenditures for these “other services” and enter the amounts in item 29. In the space below the table, indicate the types of services included in “other services.”

Any expenditures that cannot be attributed to service recipients should be entered in item 31, “Administrative Costs,” not as expenditures for “other services.” “Administrative Costs” should include all other non-service uses of SSBG Expenditures (e.g., training, administrative support, or overhead costs).

The sum of all expenditures for services should be entered in the row after item 29.

Column: SSBG Expenditures. Enter the SSBG Expenditures for each service.

Subcolumn: SSBG Allocation. Expenditures may include dollars from the current year and the previous year’s allocation. The total of this column may differ from the total amount of the annual SSBG Allocation if the full amount of the allocation was not expended during the fiscal year during which it was allocated, or if a portion of the SSBG Allocation from the previous year were expended during the reporting year.

Subcolumn: Funds Transferred into SSBG. Enter any funds expended that were transferred from other block grants into SSBG. The total of this column may differ from the total amount of the transfer if the full transfer was not expended during the fiscal year during which it was transferred or if funds transferred during an earlier year were expended during this year.

In the space below the table, indicate the block grant(s) from which these funds were transferred.

Column: Expenditures of All Other Federal, State, and Local Funds. Enter all funds expended for each service from other Federal, State, and local sources. In the space below the table, indicate the sources of these funds. If SSBG Expenditures are not reported for a particular service, do not report Expenditures of All Other Federal, State, and Local Funds for the service.

Column: Total Expenditures. In this column enter the Total Expenditures for each service. This amount should equal the sum of the three columns across the table (i.e., SSBG Allocation; Funds Transferred into SSBG; and Expenditures of All Other Federal, State, and Local Funds). If SSBG Expenditures are not reported for a particular service, do not report Total Expenditures for the service.

Column: Provision Method. If the service was provided by a public agency, put an “X” in the column marked Public. If the service was provided by a private agency, put an “X” in the column marked Private. Both columns may be marked if the service was provided by both public and private agencies.

Part B. Recipients

States are required to submit recipient data (actual or estimated) for each service for which SSBG Expenditures are reported in Part A. The total number of recipients is all recipients of services supported by the Total Expenditures, which includes SSBG Expenditures (including Funds Transferred into SSBG) and All Other Federal, State, and Local Funds.

States should, if possible, provide unduplicated counts of service recipients. That is, if an individual received a service during the reporting period, then discontinued the service, and then received the service again, the individual should only be counted once.

Recipients are reported in four age categories—Children, Adults Age 59 Years and Younger, Adults Age 60 Years and Older, and Adults of Unknown Age. The numbers of Total Adults and Total recipients are reported as well.

The sum of recipients of all service categories should be entered in the row after item 29.

Column: Children. For each service, enter the actual or estimated number of children who have received the service.

Column: Adults. For each service, enter the actual or estimated number of adults who have received the service. The sum of the three subcolumns should equal the total number of adults who have received each service (indicated in the Total Adults column).

Subcolumn: Adults Age 59 Years and Younger. Enter the actual or estimated number of adults age 59 years and younger who have received each service.

Subcolumn: Adults Age 60 Years and Older. Enter the actual or estimated number of adults age 60 years and older who have received each service.

Subcolumn: Adults of Unknown Age. Enter the actual or estimated number of adults of unknown age who have received each service.

Column: Total Adults. For each service, enter the total number of adult recipients. The amount in this column should be the sum of the three adult subcolumns—Adults Age 59 Years and Younger, Adults Age 60 Years and Older, and Adults of Unknown Age.

Column: Total. For each service, enter the total number of recipients. This should be the sum of the adults and children reported in the Children and Total Adults columns.

Electronic Report Submission

States are encouraged to submit these data electronically in addition to the paper copy form. An electronic version of the form, in Microsoft Excel format, can be downloaded from the SSBG Web site at: http://www.acf.hhs.gov/programs/ocs/ssbg.

Reports may be submitted via e-mail to Marsha Werner at mwerner@acf.hhs.gov.

The mailing address is:

Marsha Werner, SSBG Program Specialist

Office of Community Services

Administration for Children and Families

U. S. Department of Health and Human Services

370 L’Enfant Promenade, SW

Washington, DC 20447

1 Appendix B to 45 CFR Part 96—SSBG Reporting Form and Instructions, Federal Register, Volume 58, Number 218, Monday, November 15, 1993.