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Attachment II

ANNUAL BUDGET REQUEST FOR TITLE IV-9 FUNDS

OMB Approval #0980-0047
Approved thru 9/30/86

Fiscal Year 19

State of           October 1, 19           through September 30, 19            Revision#

1. COMPUTATION OF FEDERAL GRANT AWARD

   1. Total estimated title IV-B expenditure:
      
      
   2. Enter Federal Share (75% of A)
   
   
   

2. REQUEST FOR GRANT AWARD

   Indicate the total request for the year and the request for each of the four quarters. (Funds totaling more than the State's share of the $141 million allotment will not be released to the State until there has been verification that the State meets the conditions of P.L. 96-272 for those funds.)

   Total (from line I.B)

   1st Q (Oct-Dec)

   2nd Q (Jan-Mar)

   3rd Q (Apr-Jun)

   4th Q (Jul-Sept)

   
   
   

3. CERTIFICATION BY STATE AGENCY

   The State Agency submits the above estimate and request of grant award under title IV-B of the Social Security Act, as amended, and agrees that the estimated expenditures will be made in accordance with the Child Welfare Services Plan, agreed to by the Agency and the Administration for Children, Youth and Families, for the fiscal year ending September 30.

(Signature) Administrator, Social Services Agency (Title--please type)	Date
(Signature) Director, Single Organizational Unit (Optional) (Title--please type)	Date

Attachments:

Attachment I - Certification of Eligibility for Additional Funds Under Section 427 of the Social Security Act
Attachment III - Annual Summary of Child Welfare Services
Attachment IV - Instructions for the Preparation of the Annual Summary of Child Welfare Services