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Administration for Children and Families US Department of Health and Human Services
 
Office of Community Service (left header) skip to primary page contentIncreasing the Capacity of Individuals, Families and Communities (right header)

APPENDIX C. SSBG REPORTING FORM

(Download PDF)
Part A. Expenditures and Provision Method OMB NO.: 0970-0234
  EXPIRATION DATE: 05/31/2008
STATE: FISCAL YEAR: REPORT PERIOD:
Contact Person: Phone Number:  
Title: E-Mail Address:
Agency: Submission Date:
 
Service Supported with SSBG Expenditures SSBG Expenditures Expenditures of All Other Federal, State and Local funds** Total Expenditures Provision Method
SSBG Allocation Funds transferred into SSBG* Public Private
1 Adoption Services            
2 Case Management            
3 Congregate Meals            
4 Counseling Services            
5 Day Care--Adults            
6 Day Care--Children            
7 Education and Training Services            
8 Employment Services            
9 Family Planning Services            
10 Foster Care Services--Adults            
11 Foster Care Services--Children            
12 Health-Related Services            
13 Home-Based Services            
14 Home-Delivered Meals            
15 Housing Services            
16 Independent/Transitional Living Services            
17 Information & Referral            
18 Legal Services            
19 Pregnancy & Parenting            
20 Prevention & Intervention            
21 Protective Services--Adults            
22 Protective Services--Children            
23 Recreation Services            
24 Residential Treatment            
25 Special Services--Disabled            
26 Special Services--Youth at Risk            
27 Substance Abuse Services            
28 Transportation            
29 Other Services***            
30 SUM OF EXPENDITURES FOR SERVICES            
31 Administrative Costs            
32 SUM OF EXPENDITURES FOR SERVICES AND ADMINISTRATIVE COSTS            
* From which block grant(s) were these funds transferred?
** Please list the sources of these funds:
*** Please list other serivces:

Part B. Recipients OMB NO.: 0970-0234
  EXPIRATION DATE: 05/31/2008
STATE:  
FISCAL YEAR:
 
Service Supported with SSBG Expenditures Children Adults Total Adults Total
Adults Age 59 Years & Younger Adults Age 60 Years & Older Adults of Unknown Age
1 Adoption Services            
2 Case Management            
3 Congregate Meals            
4 Counseling Services            
5 Day Care--Adults            
6 Day Care--Children            
7 Education and Training Services            
8 Employment Services            
9 Family Planning Services            
10 Foster Care Services--Adults            
11 Foster Care Services--Children            
12 Health-Related Services            
13 Home-Based Services            
14 Home-Delivered Meals            
15 Housing Services            
16 Independent/Transitional Living Services            
17 Information & Referral            
18 Legal Services            
19 Pregnancy & Parenting            
20 Prevention & Intervention            
21 Protective Services--Adults            
22 Protective Services--Children            
23 Recreation Services            
24 Residential Treatment            
25 Special Services--Disabled            
26 Special Services--Youth at Risk            
27 Substance Abuse Services            
28 Transportation            
29 Other Services            
30 SUM OF RECIPIENTS OF SERVICES