Data collection form instructions

THE ADMINISTRATION ON AGING (AoA)

ADDITIONAL INSTRUCTIONS FOR COMPLETING

FINANCIAL STATUS REPORT

AND

SUPPLEMENTAL FORM TO SF-269

General Instructions

1) All amounts reported should be rounded off to the nearest dollar; no cents should be reported.

2) Leave blank items 10.c and 10.g since the Deductive and the Matching or Cost Sharing alternatives are not allowed.

3) The amount reported in item 10.e should represent non-State, subrecipient contributions (i.e. those non-Federal resources contributed by AAA's, nutrition and service providers, etc.).

4) The amount reported in item 10.h should represent those outlays made from State resources.

5) Item 10.k should include the total Federal and State share of unliquidated obligations. These would include State funds awarded to subrecipients (AAA's, etc.) which have not been earned/expended.

6) Item 10.l, the State and subrecipient’s share from 10.k above.

7) Please note that program income used in accordance with the Additional Alternative (Item 10.r) is a CUMULATIVE AMOUNT and should not be included in the total outlays on line 10.a.

8) In Item 13, all 4 blocks should be completed--printed signature, written signature, telephone number, and date.

Since the current form does not have multiple columns for reporting more than one program function, State Agencies are required to break down the following items on the Supplemental Form to the SF 269. States which are a Single State Planning and Service Area and do not have Area Agencies on Aging (AAA) are also required to complete the AoA Supplemental Form with each submission.  This includes all lines and columns, except where a line is specifically designated for an Area Agency on Aging (AAA), such as Item 10.o, Area Plan Administration.

ITEM 10.i Total recipient share of net outlays.

Sections 304 and 308 of the Older Americans Act and Section 1321.47 of the Title III regulations require a match of 25 percent for State and Area Plan administration, 15 percent for Part B and C Services, and 25% for Part E Services. In Item 10.i, Column III, identify the total non-Federal amount expended for State and Area Plan Administration on the first (ADMIN) line. Break out the remaining non-Federal share of outlays in the spaces provided for each program service.

• Under Part B, because the 15% match is calculated after funds for LTCO have been set aside by the State, the amount recorded should exclude LTCO (Part B) funds. LTCO (Part B) funds should be recorded on the LTCO (Part B) Only line.

• Under Part E, states may not use more than 10 percent of the total federal and non-federal share available to the state to provide support services to grandparents and older individuals who are relative caregivers of a child who is not more than 18 years of age. Part E should be broken out to identify the amount of non-Federal funds expended for support services to grandparents and relative caregivers. The Grandparent amount should be included in the Part E line and recorded on the Grandparent line.

ITEM 10.j Federal share of net outlays.

In Item 10.j, Column III, identify the total Federal amount expended for State and Area Plan Administration on the first (ADMIN) line. Break out the remaining Federal share of outlays in the spaces provided for each program service.

• No federal dollars expended for any program may exceed the amount of Federal dollars allotted for that program on the last grant award for that fiscal year, including transfer grants. If the amount is exceeded due to transfers, please explain in Line 12.

• Under Part B, the amount recorded should exclude LTCO (Part B) funds. LTCO (Part B) funds should be recorded on the LTCO (Part B) Only line.

• Under Part E, states may not use more than 10 percent of the total federal and non-federal share available to the state to provide support services to grandparents and older individuals who are relative caregivers of a child who is not more than 18 years of age. Part E should be broken out to identify the amount of Federal funds expended for support services to grandparents and relative caregivers. The Grandparent amount should be included in the Part E line and recorded on the Grandparent line.

ITEM 10.o Total Federal funds authorized for this funding period.

The break down of Item 10.o should be the State's allocation of Federal funds for the following program functions in the indicated sections of the supplemental form:

State Administration/Administrative Activities.

Sections 308(a)(1) and (b)(2) provide the authority for States to expend the greatest of 5% of their total allotment or $500,000 for this function. Provide the total amount of Title III funds used for State Administration on Line 1. This total must be broken down further to identify the amount of funds utilized from each program allotment.

Part B, Supportive Services; Part C1, Congregate Meals; and Part C2, Home Delivered Meals

Sections 308 (b)(4) and (5) provide the authority for States to transfer between Title III-B and III-C and Titles III-C1 and C2. Provide the amount utilized by the State after transfers for each of the three program allotments on Lines 2, 4, and 5 respectively. Part B Funds for the Long-Term Care Ombudsman program should also be included in Part B, Line 2. A final grant award is issued to states by September 30th each year, the last day of the Federal Fiscal Year (FFY).  This reflects all transfers that have taken place in the state for that FFY.  These transfers may be between Title III-B and III-C and between Titles III-C1 and C2.  From September 30th forward, Item 10.o must show the same amounts as the final Statement of Grant award for that FFY. If Item 10.o is allocating funds on the basis of transfers before the final transfer grant is issued, please state so in Line 12.

Long-Term Care Ombudsman

Sections 304(d)(1)(B) and 307(a)(9) provide the authority to utilize Part B funds for Long-Term Care Ombudsman services. Provide the amount of Fiscal Year 2000, Title III-B funds utilized by the State for costs incurred by the State Agency in support of the Statewide Long-Term Care Ombudsman program. The total Federal funds authorized for this purpose must equal or exceed the amount spent in the base year 2000, and should be recorded on Line 3 and included in the Part B amount in Line 2 above.

Part D, Disease Prevention and Health Promotion Services

Section 303(d) authorizes funds for grants under Part D. Provide the amount of Title III

funds utilized for preventive health services on Line 6.

Part E, National Family Caregiver Support Program

Sections 303 (e)(1) and (2) authorize funds for grants under Part E. Provide the amount of Title III funds utilized for caregiver services on Line 7. Under Part E, states may not use more than 10 percent of the total federal and non-federal share available to the state to provide support services to grandparents and older individuals who are relative caregivers of a child who is not more than 18 years of age.

Area Plan Administration

Sections 304(d)(1)(A) and 308(a)(3) provide the authority for States to utilize a maximum of 10% of their total allotment for Area Plan Administration after the allocation of funds for State plan administration. This total must be broken down further to identify the amount of funds utilized from each program allotment. The allotment for Part D may be included in the 10% computation, but no funds may be taken from Part D.

ITEM 10.p Unobligated funds

Breakdown the total unobligated Federal funds by Part/Subpart. If the report being submitted is a final report, please indicate in Line 12 if those funds have or have not been drawn down from the Payment Management System (PMS).

ITEM 10.r Disbursed program income using the additional alternative.

Breakdown the cumulative amount of program income disbursed by Part/Subpart. Disbursed program income must be reported on the SF269 for the fiscal year in which the program income was earned (45 CFR Part 92.21(f)(2)).