1. State or ITO:

2. EIN:

3. Address:

4. Submission: [ ] New [ ] Revision

Description of Funds

Estimated Expenditures

Expenditures

Number served

Population served

Geographic area served

Individuals

Families

• Federal Title IV-B, Subpart 1 Funds

$

$

a) Total Administrative Costs (not to exceed 10% of Federal allotment)

$

$

6. Total Federal title IV-B, Subpart 2 Funds. (This amount should equal the sum of lines a – f).

$

$

• Family Preservation Services

$

$

b) Family Support Services

$

$

c) Time-Limited Family Reunification Services

$

$

d) Adoption Promotion and Support Services

$

$

e) Total for Other Service Related Activities (e.g. planning).

$

$

f) Total Administrative Costs (not to exceed 10% of

total allotment after October 1, 2007)

$

$

$

$

a) Indicate the amount of State’s allotment spent on room and board for eligible youth (not to exceed 30% of CFCIP allotment).

$

$

$

$

9. Certification by State Agency or Indian Tribal Organization (ITO). The State agency or ITO agrees that expenditures were made in accordance with the Child and Family Services Plan, which has been jointly developed with, and approved by, the Children's Bureau, for the Fiscal Year ending September 30, 20__.

Signature and Title of State/Tribal Agency Official

Date

Signature and Title of Regional Office Official

Date