ACL SF-425 T-3 Supplemental Form-Financial Status for ACL Title III Gra

FEDERAL FINANCIAL REPORT (FFR)
ACL/AOA TITLE III SUPPLEMENTAL FORM TO SF-425
STATE:

FY:

DATE SUBMITTED:
FINAL REPORTS: ____PART B

Item 10 d.

REPORTING PERIOD ENDED:
____PART C-1

____PART C-2

____PART D

____PART E

Total Federal Funds Authorized:
Total Part B

All Parts

Total State Plan Administration

Total Part C-1

All Parts

Total Area Plan Administration

Total Part C-2
Total Part D

Total Part E

Total All Parts

Item 10 e.

Federal Share of Expenditures:
State

Part B
Part B
Part B

Non-State

Administration
LTCO
Supportive Services
Total Part B

Part C-1 Administration
Part C-1 Congregate Meals
Total Part C-1

Part C-2 Administration
Part C-2 Home Delivered Meals
Total Part C-2

Part D
Part D

State Plan Administration

Preventative Health
Total Part D

Part E
Part E
Part E

Administration
Older Relative Caregiver Only
Caregiver Services
Total Part E

Total All Parts
Total Adminstration
Total B, C1, C2 Services

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number
(OMB 0985-0004). Public reporting burden for this collection of information is estimated to average 2 hours per response, including time for gathering and maintaining the data
needed and completing and reviewing the collection of information.

OMB No. 0985-0004
Expires 11/30/2020

Item 10 i.
Part B
Part B
Part B

Total Recipient Share Required:

Administration
LTCO
Supportive Services

Match Percentage
25%
0%
15%
Total Part B

Part C-1 Administration
Part C-1 Congregate Meals

25%
15%
Total Part C-1

Part C-2 Administration
Part C-2 Home Delivered Meals

25%
15%
Total Part C-2

Part D
Part D

State Plan Administration

Preventative Health

25%
0%
Total Part D

Part E
Part E
Part E

Administration
Older Relative Caregiver Only
Caregiver Services

25%
25%
25%
Total Part E

Total All Parts

Item 10 j.

Total Recipient Share of Expenditures:
State

Part B
Part B
Part B

Non-State

Administration
LTCO
Supportive Services
Total Part B

Part C-1 Administration
Part C-1 Congregate Meals
Total Part C-1

Part C-2 Administration
Part C-2 Home Delivered Meals
Total Part C-2

Part D
Part D

Administration
Preventative Health
Total Part D

Part E
Part E
Part E

Administration
Older Relative Caregiver Only
Caregiver Services
Total Part E

Total All Parts
Total Adminstration
Total B, C1, C2 Services

Comments:

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control
number (OMB 0985-0004). Public reporting burden for this collection of information is estimated to average 2 hours per response, including time for gathering and
maintaining the data needed and completing and reviewing the collection of information.

OMB No. 0985-0004
Expires 11/30/2020