APPENDIX B. SSBG REPORTING FORM

Part A. Expenditures and Provision Method					OMB NO.: 0970-0234
Part A. Expenditures and Provision Method					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
Service Supported with SSBG Expenditures		SSBG Allocation	Funds transferred into SSBG*	Expenditures of All Other Federal, State and Local funds**	Total Expenditures	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 services:

Part B. Recipients					OMB NO.: 0970-0234
Part B. Recipients					EXPIRATION DATE: 05/31/2008
STATE:
FISCAL YEAR:
Service Supported with SSBG Expenditures		Children	Adults			Total Adults	Total
Service Supported with SSBG Expenditures		Children	Adults Age 59 Years & Younger	Adults Age 60 Years & Older	Adults of Unknown Age	Total Adults	Total
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