Form 1 CSBG Eligible Entity Master

OMB Control No: 0970-0382

Expiration date:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average 1.67 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

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.

Community Services Block Grant (CSBG)

Model State Plan

Eligible Entities Master List

The following is a listing of all CSBG Eligible Entities within your state. This should include all eligible entities that receive funding under the “not less than 90% funds” of your CSBG Allocation. This information will be used to complete questions regarding your eligible entities within the State Plan and Annual Report. As well as be used as a tracking tool in the case that the name of an entity changes, there are designations or re-designations, terminations or reductions, or mergers.

Do not include entities that only receive remainder/discretionary funds from the state or tribes/tribal organizations that receive direct funding from OCS under Section 677 of the CSBG Act.

Note: Whether nonprofit or public, entities that receive CSBG funds are generally considered to be Community Action Agencies for the purpose of administering CSBG. The only specific exceptions outlined in the CSBG Act are Limited Purpose Agencies, Migrant and Seasonal Farmworker organizations, and Tribes and Tribal Organizations

Instructional Note: Limited Purpose Agency refers to an eligible entity that was designated as a limited purpose agency under Title II of the Economic Opportunity Act of 1964 for fiscal year 1981, that served the general purposes of a community action agency under Title II of the Economic Opportunity Act, that did not lose its designation as a limited purpose agency under Title II of the Economic Opportunity Act as a result of failure to comply with that Act and that has not lost its designation as an eligible entity under the CSBG Act.

Instructional Note: 90 percent funds are the funds a state provides to eligible entities to carry out the purposes of the CSBG Act, as described under Section 675C of the CSBG Act. A state must provide “no less than 90 percent” of their CSBG allocation, under Section 675B, to the eligible entities.

DUNS #	CSBG Eligible Entity Official Name	CSBG Eligible Entity DBA	Official Address				Geographical Area	Public or Non-profit	Type of Entity
			Street Address	City	State	Zip Code
Provide the entity DUNS #. Do not include dashes. [REQUIRED, Numeric field, 10 characters]	Provide the official name of the CBSG Eligible Entity as registered with the DUNS. Note: This information will populate CSP Tables 5.1., 7.2., and 10.1.; [REQUIRED, Narrative, 500 characters]	Provide the “doing-business-as” name of the CSBG Eligible Entity, if different from the organization’s official name. If no dba, leave blank. [OPTIONAL, Narrative, 500 characters]				Provide the official street address of the CSBG Eligible Entity. [REQUIRED, Narrative, 250 characters]	Provide the official city of the CSBG Eligible Entity. [REQUIRED, Narrative, 50 characters]	This field will auto-populate.	Provide the official city of the CSBG Eligible Entity. [REQUIRED, Numeric, 5 characters]