1. State or ITO:

2. EIN:

3. Address:

4. Submission:

[ ] New [ ] Revision

5. Total estimated title IV-B, Subpart 1 Funds

$

    a) Total administration (not to exceed 10% of estimated allotment)

$

6. Total estimated title IV-B, Subpart 2 Funds (FOR STATES: This amount should equal the sum of lines a-g.)

$

    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) Monthly Caseworker Visits (STATES ONLY)

$

    g) Total Administration (FOR STATES: not to exceed 10% of estimated allotment)

$

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

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) State Grant (no State match required)

Estimated Amount $____________, plus additional allocation, as available.

9. Estimated Chafee Foster Care Independence Program (CFCIP) funds. (FOR STATES ONLY)

$

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

$

10. Estimated Education and Training Voucher (ETV) funds.

$

11. Re-allotment of CFCIP and ETV Program Funds:

    a) Indicate the amount of the State’s allotment that will not be required to carry out CFCIP $___________.

    b) Indicate the amount of the State’s allotment that will not be required to carry out ETV $___________.

    c) If additional funds become available to States, specify the amount of additional funds the State is requesting for CFCIP $___________________ for ETV program $_________________________.

12. 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 State Grant, CFCIP and ETV programs, 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, 20__.

Signature and Title of State/Tribal Agency Official

Signature and Title of Central Office Official