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ATTACHMENT C

STATE INFORMATION ON THE INDEPENDENT LIVING PROGRAM STATE

The State information provided below will be considered permanent and will remain in effect unless rescinded by the State, after notification in writing to the Commissioner, ACYF.

Name of Agency Administering the ILP:    __________________________________________________________________________________________

Employer Identification Number (EIN):   _____________________________________________________________________________________

ADMINISTRATION OF STATE   State Administered   ________   County Administered _________

* If county administered, please describe the following:

1. The precise legal relationship between the State and the counties with regard to the ILP and the expenditure of funds.
2. How does the State enter into agreements with the counties’
3. Does the State delegate responsibility to the counties’
4. Are there written agreements’

5. Are there provisions for such agreements in State law or in the State plan’

STATE MATCHING INFORMATION

1. The State will apply for and match the additional funds over the $45 million basic amount.

   Yes   ____________*       No   _____________

   If yes, All   ______________________   or    $________________________

2. If funds become available-through reallotment, the state will apply for and match these funds.

   Yes   ____________*       No   _____________

   If yes, All   ______________________   or    $________________________

   If yes to either item, indicate "ALL" or specify the amount of additional and the amount of reallotted funds the State will apply for and match (dollar-for-dollar).

ELIGIBLE POPULATION

1. The State elects to serve non-IV-E eligible youth.

   Yes   __________      No   _________

2. The State elects to serve former foster care youth.

   Yes   __________      No   _________

3. The State elects to serve youth up to age 21.

   Yes   __________      No   _________

   If yes to any of the above, describe how the State will integrate the additional client population into planning for and implementation of the ILP.

TRUST FUNDS

The State elects to establish trust funds for youth leaving foster care.

Yes   __________      No   _________

If yes, please describe:

1. How will the trust funds be financed’
2. How will the trust funds be integrated into the overall individual independent living plan’
3. What are the rules that will govern the use of and disbursement from such trust funds’
4. What safeguards will be employed to ensure that no Federal ILP funds contributed to the trust fund are later used for the provision of room and board’

________________________________________________________

Signature Title

________________________________________________________

Agency/Organization

Attachments:

Attachment A:  ACYF-PI-93-16
Attachment B:  FY 1998 Independent Living Program Allotments
Attachment D:   Certifications
Attachment E:  List of Regional Administrators, ACF