CFS-101, PART I: ANNUAL BUDGET REQUEST FOR TITLE IV-B, SUBPART 1; 2 FUNDS, CAPTA, AND ILP

FISCAL YEAR _____ OCTOBER 1, ______ through SEPTEMBER 30, ______

1. State or ITO			2. EIN:
3. Address:			4. Submission: [ ] New [ ] Revision
5. Estimated title IV-B, Subpart 1 Funds
a) Total Estimate
b) Federal Share [75% of 5(a)]
c) State/ITO Match [25% of 5(a)]
6. Estimated title IV-B, Subpart 2 Funds
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
g) Total Estimate [6(a)+6(b)+6(c) +6(d) + 6(e) + 6(f)]
h) Federal Share [75% of 6(g)]
i) State/ITO Match [25% of 6(g)]
7. Indian tribal Organizations Only (Title IV-B, Subpart 2 Only) If additional funds become available to ITOs, the ITO may apply in advance for and match these funds. Specify the amount of additional funds the ITO will apply for and match. Total Amount $ _____________ Federal Share(75%) $ ___________ ITO Match(25%) $ _________
8. Child Abuse Prevention and treatment Act (CAPTA), Child Abuse and Neglect Basic State Grant Only. Please include any additional funds due as a result of reallocations that may occur. Estimated BSG Amount $ _____________, plus additional allocation, as available.
9. Estimated title IV-E, Independent Living Funds (ILP)	FEDERAL			STATE
a) Total Estimate State's share of $45 million
b) Additional funds at 50% match
c) Maximum amount of reallotted funds requested
10. Certification by State Agency The State agency or Indian tribe submits the above estimate and request of funds under title IV-B, subpart 1 and/or 2, of the Social Security Act, for States only CAPTA BSG and the ILP, and agrees that the estimated expenditures will be made in accordance with the Child and Family Services Plan, which has been jointly developed with the ACF Regional Office and has been determined to meet all the requirements of the Act, for the Fiscal Year ending September 30.
Signature and Title of State/tribal Agency Official		Signature and Title of Regional Office Official
Date		Date