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Attachment E

1.   State or ITO				2.   EIN:
3.   Address:				4.   Submission: [ ] New   [ ] Revision
5.   Estimated title IV-B, Subpart 1 Funds
a)   Total Estimate
b)   Federal Share [75% of 5(a)]
c)   State/ITO Match [25% of 5(a)]
6.   Estimated title IV-B, Subpart 2 Funds
a)   Total Family Preservation Services
b)   Total Family Support Services
c)   Total Time-Limited Family Reunification Services
d)   Total Adoption Promotion and Support Services
e)   Total for Other Service Related Activities (e.g. planning)
f)   Total Administration
g)   Total Estimate [6(a)+6(b)+6(c) +6(d) + 6(e) + 6(f)]
h)   Federal Share [75% of 6(g)]
i)   State/ITO Match [25% of 6(g)]
7.   Indian tribal Organizations Only (Title IV-B, Subpart 2 Only) If additional funds become available to ITOs, the ITO may apply in advance for and match these funds. Specify the amount of additional funds the ITO will apply for and match. Total Amount   $ _____________   Federal Share(75%)   $ ___________   ITO Match(25%)   $ _________
8.   Child Abuse Prevention and Treatment Act (CAPTA), Basic State Grant (BSG) Only. Please include any additional funds requested as a result of reallocations that may occur. Estimated BSG Amount   $   _____________, plus additional allocation, as available.
9. Chafee Foster Care Independence Program Total Estimate of State's share of $137.9 million						FEDERAL	STATE
10.   Certification by State Agency The State agency or Indian Tribe submits the above estimate and request of funds under title IV-B, subpart 1 and/or 2, of the Social Security Act; for States only, CAPTA BSG and the CFCIP, and agrees that the estimated expenditures will be made in accordance with the Child and Family Services Plan, which has been jointly developed with the ACF Regional Office and has been determined to meet all the requirements of the Act, for the Fiscal Year ending September 30.
Signature and Title of State/tribal Agency Official				Signature and Title of Regional Office Official
Date				Date

Attachments

Attachment A: Major ICWA Requirements

Attachment B: ACYF-CB-PI-01-02, February 13, 2001

Attachment C: Title IV-B and CAPTA FY 2002 Estimated Allotments

Title IV-B, Subpart 1, Child Welfare Services Fiscal Year 2002 Estimates

Title IV-B, Subpart 1, Child Welfare Services Fiscal Year 2002 Estimates: Child Population and Federal Share Of Funds

Title IV-B, Subpart 2, Promoting Safe and Stable Families

Title IV-B, Subpart 2, Promoting Safe and Stable Families: FY2002 Indian Tribe Estimated Allotments

Child Abuse and Neglect Prevention and Treatment Act (CAPTA) FY 2002 Estimated Allotments

Attachment D: Title IV-B and CAPTA FY 2001 Final Allotments

Title IV-B Subpart 1, Child Welfare Services FY 2001 Allotments

Title IV-B Subpart 1, Child Welfare Services FY 2001 Allotments: Child Population and Federal Share Of Funds

Title IV-B Subpart 2, Promoting Safe and Stable Families: Final State Allotments - FY 2001

Title IV-B Subpart 2, Promoting Safe and Stable Families: Final Tribal Allotments - FY 2001

Child Abuse and Neglect Prevention and Treatment Act - Final State Allotments - FY 2001

Attachment E: CFS 101, Part I, Annual Budget Request and Part II, Annual Summary of Child and Family Services

CFS-Instructions

CFS-101, Part I: Annual Budget Request for Title IV-E, Subparts 1 and 2, CAPTA and Independent Living Program

CFS-101, Part II

Annual Summary of Child and Family Services

Attachment F: ACF Regional Administrators and Hub Directors