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Attachment F

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

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

CFS-101, Part I: Annual Budget Request for Title IV-B, Subparts 1 and 2, CAPTA, Chafee Foster Care Independence (CFCIP) and Education and Training Voucher (ETV) Program Instructions

Note: While the information on the programs are consolidated into one Child and Family Services Plan (CFSP), eligibility and expenditure reports for the individual programs are separate. Funding will not be delayed for one program due to potential eligibility issues in another program.

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 Federal 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. A 25% State match is required and the State or Tribe's match amount should be reflected on the final SF-269 report.

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

   Specify the total estimated amount of title IV-B, subpart 2 Federal 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. A 25% State match is required and the State or Tribe's match amount should be reflected on the final SF-269 report.

   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 Federal funds that the State or Tribe is requesting if additional funds become available.
   
   

8. Child Abuse Prevention and Treatment Act (CAPTA) (States only).

   Indicate the State's estimated CAPTA 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.

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.

10. Estimated Funds Allotted under Section 477 for Education and Training Vouchers (ETV) (States only)

11. Re-allotment of CFCIP and/or ETV funds for States

    The Administration for Children and Families (ACF) is able to re-allot unneeded portions of State allocations of CFCIP and ETV funds to other States so that the total appropriation remains available for program purposes. In order for a State to be awarded portions 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.

    a) 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.

    b) 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 ETV activities.

    c) Indicate the amount of funds the State is requesting if additional funds become available for CFCIP and/or ETV. A 20% State match is required. The State match amount should be reflected on the final SF-269 report.

12. 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.

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

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

CFS-101, Part I: Annual Budget Request For Title IV-B, Subpart 1 & 2 Funds, CAPTA, Chafee Foster Care Independence Program (CFCIP) and Education and Training Vouchers (ETV): Fiscal Year 20__, October 1, 20__ through September 30, 20__

1. State or ITO:		2. EIN:
3. Address:		4. Submission: [ ] New     [ ] Revision
5. Estimated Federal title IV-B, Subpart 1 Funds.		$
6. Total Estimated Federal title IV-B, Subpart 2 Funds. (This amount should equal the sum of lines a - f.)		$
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. 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.		$
10. Estimated Education and Training Voucher (ETV) funds.		$
11. Re-allotment of CFCIP and ETV 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 $___________________ .
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 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

ACYF-CB-PI-04-02     HTML or PDF (328 KB)
Attachment A:	Promoting Safe and Stable Families (PSFF) Tribal FY 2004 Allocations HTML or PDF (9 KB) Title IV-B, Subpart 1 - Child Welfare Services Tribal Child Population and Federal Share of Funds Fiscal Year (FY) 2004 Allotments HTML or PDF (28 KB)
Attachment B:	Current Variances in Title IV-B Provisions of Law and Regulation HTML or PDF (93 KB)
Attachment C:	CFSP/APSR Program Instruction (PI) Grid HTML or PDF (81 KB)
Attachment D:	Preparing for the FY 2005-2009 Tribal Child and Family Services Plan HTML or PDF (14 KB)
Attachment E:	Title IV-B Child And Family Services Plan: Assurances HTML or PDF (14 KB)
Attachment F:	CFS-101, Part I: Annual Budget Request for Title IV-B, Subparts 1 and 2, CAPTA, Chafee Foster Care Independence (CFCIP) and Education and Training Voucher (ETV) Program Instructions HTML or PDF (15 KB) CFS-101, Part II: Annual Summary of Child and Family Services Instructions HTML or PDF (17 KB) CFS-101, Part II: Annual Summary of Child and Family Services Form HTML or PDF (23 KB)
Attachment G:	Regional Administrators HTML or PDF (67 KB)