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Attachment C
OMB Approval #0980-0047
Approved through July 31, 2005

U.S. Department of Health and Human Services
Administration for Children and Families

CFS-101, PART I: ANNUAL BUDGET REQUEST FOR TITLE IV-B, SUBPARTS 1 AND 2, CAPTA AND CHAFEE FOSTER CARE INDEPENDENCE PROGRAM INSTRUCTIONS

(Complete separate forms for each fiscal year)

1. Enter the name of the State or Indian Tribal Organization (ITO).

2. Indicate the Employer Identification Number (EIN).

3. Enter the address of the State or ITO Agency.

4. Indicate if this is a new or revised budget request.

5. Estimated title IV-B, subpart 1 funds:

   Specify the estimated amount of title IV-B, subpart 1 funds that the State or ITO expects to spend during the fiscal year on Child Welfare Services. The previous Federal Fiscal Year's (FFY) final allotment as provided in the annual Program Instruction on the Annual Progress and Services Report (APSR) is to be used as the estimated amount for the State's/Tribe's request.

6. Estimated title IV-B, subpart 2 funds:

   Specify the total estimated amount of title IV-B, subpart 2 funds that the State or ITO expects to spend during the fiscal year on Promoting Safe and Stable Families services. The previous Federal Fiscal Year's (FFY) final allotment as provided in the annual Program Instruction on the APSR is to be used as the estimated amount for the State's/Tribe's request.

   1. Specify the estimated amount of title IV-B, subpart 2 funds to be spent during the fiscal year for Family Preservation Services.

   2. Specify the estimated amount of title IV-B, subpart 2 funds to be spent during the fiscal year for Family Support Services.

   3. Specify the estimated amount of title IV-B, subpart 2 funds to be spent during the fiscal year for Time-Limited Family Reunification Services.

   4. Specify the estimated amount of title IV-B, subpart 2 funds to be spent during the fiscal year for Adoption Promotion and Support Services.

   5. Specify the estimated amount of title IV-B, subpart 2 funds to be spent during the fiscal year for other service related activities (e.g. planning).

   6. Specify the estimated amount of title IV-B, subpart 2 funds to be spent on Administration (not to exceed 10% of the estimated allotment).

7. Re-allotment of Title IV-B, Subpart 2 funds for State and Indian Tribal Organizations

   The Administration for Children and Families (ACF) is able to re-allot unneeded portions of State and Tribal allocations of title IV-B, subpart 2 funds to other States and eligible Indian Tribes so that the total appropriation remains available for program purposes. In order for a State or ITO to be awarded a portion of these funds, or for funds to be released, ACF must have on file a request from the State or Indian Tribe for additional funds, or the release of funds.

   1. Indicate the amount of funds that:

      1. the State or Tribe does not expect to utilize for the upcoming fiscal year; or
      2. an amount that the State or Tribe is requesting if funds become available in order to carry out the activities in the CFSP.
      
      
      

   2. Indicate the amount of funds that the State or Tribe is requesting if additional funds become available.

8. Child Abuse Prevention and Treatment Act (CAPTA), Basic State Grants Only (States only).

   Indicate the State's estimated CAPTA Basic State Grant allocation as provided in the annual Program Instruction on the APSR. Supplemental funds may be available for distribution if there are States that are not awarded grant funds or there are unobligated funds available for redistribution. No matching funds are required for this grant.

   Note: Pooled funding among the programs is not allowed, since separate funding streams and accountability are still required by statute. While the information on the programs may be consolidated into one Child and Family Services Plan (CFSP), eligibility and funding for the individual programs will be kept separate and funding will not be delayed for one program due to potential eligibility issues in the other program.

9. Estimated Chafee Foster Care Independence Program (CFCIP) Funds (States only)

   Indicate the estimated amount of CFCIP funds that the State expects to spend during the fiscal year on independent living activities as provided in the annual Program Instruction on the APSR.

   Note: Pooled funding among the programs is not allowed, since separate funding streams and accountability are still required by statute. While the information on the programs may be consolidated into one Child and Family Services Plan (CFSP), eligibility and funding for the individual programs will be kept separate and funding will not be delayed for one program due to potential eligibility issues in the other program.

10. Re-allotment of CFCIP funds for States

    The Administration for Children and Families (ACF) is able to re-allot unneeded portions of State allocations of CFCIP funds to other States so that the total appropriation remains available for program purposes. In order for a State to be awarded a portion of these funds, or for funds to be released, ACF must have on file a request from the State for additional funds, or the release of funds.

    1. Indicate the amount of funds that the State does not expect to utilize from their allotment during the upcoming fiscal year to carry out the CFCIP activities.

    2. Indicate the amount of funds the State is requesting if additional funds become available.

11. Certification: This report must be signed and dated in the spaces provided. The signature and title of the official of the State agency, or Indian Tribal Organization, with authority to administer or supervise the administration of title IV-B, subparts 1 and 2 programs and, for States only, the CAPTA and CFCIP programs, must be included.

    The tentative allocations are based on the premise that all States and Indian Tribes will apply for and receive the funds available to them. In the event that not all States or Indian Tribes apply for or receive their tentative allocations, those funds will be redistributed among eligible States and Indian Tribes, where permitted by statute. States receiving additional funds as a result of such a redistribution should submit information on the proposed use of such additional funds to the appropriate Regional Office of the Administration for Children and Families in the State's/Tribe's APSR. By signing this form the State/Tribal official assures that the State/Tribe will meet all applicable match requirements.

CFS-101, Part I: Annual Budget Request For Title IV-B, Subpart 1 & 2 Funds, CAPTA, And Chafee Foster Care Independence Program Fiscal Year 20__, October 1, 20__ through September 30, 20__

1. State or ITO:		2. EIN:
3. Address:		4. Submission: [ ] New     [ ] Revision
5. Estimated title IV-B, Subpart 1 Funds (25% State match required).		$
6. Total Estimated title IV-B, Subpart 2 Funds. (This amount should equal the sum of lines a - f.) (25% State match required.)		$
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 (not to exceed 10% of estimated allotment).		$
7. Re-allotment of Title IV-B, Subpart 2 funds for State and Indian Tribal Organizations (25% State match required). a) Indicate the amount of the State's/Tribe's allotment that will not be required to carry out the Promoting Safe and Stable Families program. $______________ b) If additional funds become available to States and ITOs, specify the amount of additional funds the State or Tribes is requesting. $_________________
8. Child Abuse Prevention and Treatment Act (CAPTA) Basic State Grant Only (no State match required) Estimated BSG Amount $________________, plus additional allocation, as available.
9. Estimated Chafee Foster Care Independence Program (CFCIP) funds (20% State match required).		$
10. Re-allotment of CFCIP Funds (20% State match required). a) Indicate the amount of the State's allotment that will not be required to carry out CFCIP $___________. b) If additional funds become available to States, specify the amount of additional funds the State is requesting $___________________.
11. Certification by State Agency and/or Indian Tribal Organization. The State agency or Indian Tribe submits the above estimates and request for funds under title IV-B, subpart 1 and/or 2, of the Social Security Act, CAPTA BSG and CFCIP, and agrees that expenditures will be made in accordance with the Child and Family Services Plan, which has been jointly developed with, and approved by, the ACF Regional Office, 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

ACYF-CB-PI-03-05	HTML or PDF (123 KB)
Attachment A	Title IV-B, subparts 1 and 2, CAPTA, CFCIP FY 2003 Allotments HTML
Attachment B	CFCIP FY 2004 Estimated Allotments HTML or PDF (57 KB)
Attachment C	CFS-101, Part I, Annual Budget for Title IV-B, subparts 1 & 2 HTML or PDF (72 KB)
Attachment C	CFS-101, Part II, Annual Summary of Child and Family Services Instructions HTML or PDF (71 KB)
Attachment C	CFS-101, Part II, Annual Summary of Child and Family Services HTML or PDF (93 KB)
Attachment D	ACF Regional Administrators HTML or PDF (61 KB)

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