Supplemental Form to the Financial Status Report for all AoA Title III Grantees

Forms and Documents

Document Name	Status
Form No. 1 Supplemental Form to the Financial Status Report for all AoA Title III Grantees Form and Instruction	Modified
269_Supplemental_Form_Instructions_to_OMB[1].doc Supplementary Document	2007-08-29
Supporting Statement for Title III Supplement (SF-425) 9-15-17 (3) (2).docx Supporting Statement A	2017-10-17

IC Document Collections

IC ID	Document Title	Status
10243	Supplemental Form to the Financial Status Report for all AoA Title III Grantees Form and Instruction	Modified

ICR Details

OMB Control No: 0985-0004	ICR Reference No: 201710-0985-002
Status: Historical Active	Previous ICR Reference No: 201408-0985-001
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: Supplemental Form to the Financial Status Report for all AoA Title III Grantees
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/20/2017
	Date Received in OIRA: 10/17/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2020	36 Months From Approved	11/30/2017
Responses	112	0	112
Time Burden (Hours)	224	0	224
Cost Burden (Dollars)	0	0	0

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Abstract: The Administration for Community Living (ACL) requires grantees funded under Title III of the Older Americans Act to report semiannually on the financial status of their projects. The supplemental form of the financial status report (SF-269) provides an understanding of how projects are being administered, in conformance with legislative requirements, pertinent Federal regulations and other applicable instructions and guidelines by ACL.

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Authorizing Statute(s): US Code: 42 USC 3021 Name of Law: Programs for Older Americans
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 28068	06/20/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 45030	09/27/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Supplemental Form to the Financial Status Report for all AoA Title III Grantees	1, No. 1	Data collection form ,   Title III Supplemental Form and Instructions

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	112	112	0	0	0	0
Annual Time Burden (Hours)	224	224	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $12,890

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/17/2017

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