Financialstatus Reportand Title Iiisupplementalform Tosf-425

THE ADMINISTRATION FORCOMMUNITY LIVING(ACL)/THE ADMINISTRATION ONAGING(AoA) ADDITIONALINSTRUCTIONS FOR COMPLETING

FINANCIALSTATUS REPORTAND TITLE IIISUPPLEMENTALFORM TOSF-425

SF425General Instructions:

SubmitaseparateSF-425foreach grant award(Part)oftheTitle IIINotice ofAward.

SubmitaSINGLEcombinedACL/AoA SupplementalFormwith themultipleSF-425sforeach federal fiscalyearforeachreportingperioduntilallfinalreportshavebeensubmittedforeach grant award(Parts).

Granteesareencouragedtoreportto the nearestwhole dollar.

ITEMS 1-5, 8,10.a-10.c, 10.g,10.k,10.o:use the Federal FinancialReportInstructionstocomplete.

ITEM6ReportType: note ifthereportisaSemi-Annual orFinal.

ITEM7BasisofAccounting:allreportsmustbecompletedonaccrualbasisandnotedassuch.

ITEM9Project/GrantPeriodEndDate:notetheReportingPeriodEndDate of03/31/(InsertYear) or

09/30/(insertYear).

ITEM10.f FederalShareofUnliquidatedObligations:finalreportsshouldnot haveunliquidated obligationsin10.f.Unliquidatedobligations should bereportedasan unobligatedbalance onfinalreports.

ITEM10.hUnobligatedbalance of Federalfunds:Unobligatedbalanceswill bedeobligated andwill nolonger be availablefor expenditure.

ITEM10.l TotalFederalProgram IncomeEarned:isthecumulativeamount ofprogramincomeearnedby eachgrant award(Part).Voluntary contributionsare program income(45CFR Part75.2). Program incomemustbereported ontheSF-425forthefiscalyear inwhichthe programincomewas earned(45CFR Part75.2).

ITEM10.nProgram incomeexpendedinaccordancewiththe additionalternative: isacumulative amount ofprogramincome earned thathasbeenexpendedandshouldbereported in10.nonly. Programincomeshouldnotbereportedasrecipientor Federalshareexpenditures(45CFR

75.307(e)(2)).

ITEM10.mProgram incomeexpendedinaccordancewiththe deduction alternative:leaveblank,since theDeductive andtheMatching or CostSharingalternativesare notallowedfor anypartoftheTitleIII program(45CFR 1321.67(b)).

ITEM10.oUnexpendedprogram income:voluntary contributions and cost sharing fees are programincome andmustbe disbursed beforeanyfurther Federal funds arerequested(45CFR Part75.305(b)(5)).

ITEM12Remarks: ifthereportbeingsubmittedisafinalreportnoteifthose funds haveor havenotbeen drawn down from thePaymentManagementSystem(PMS), also note if match is pooled.

ITEM13Certification:completeall5 blocks; printedsignature,writtensignature,telephone number,email address,anddate.

ACL/AoASupplemental FormtoSF-425 TitleIII:

Finalreportsshouldbemarkedonthesupplementalwhenafinalhas beensubmittedin thecurrent and/orpriorreporting periods.

Granteesareencouragedtoreportto the nearestwhole dollar.

StateAgenciesarerequiredtocomplete thebelowitemsontheSupplementalFormto theSF-425

Title III. StateswhichareaSingleStatePlanningandServiceArea and donothaveArea

AgenciesonAging(AAA) arealsorequiredtocomplete theACL/AoA SupplementalFormwith eachsubmission. Thisincludes all lines and columns, except wherea lineisspecifically

designatedfor anAreaAgencyonAging(AAA).

oThe totals foreachPartshouldtotalbackto the ITEMon theSF425form.

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ITEM10.dTotalFederalfunds authorized:onafinalreport10dmust equal10eplus10h. Total federal funds authorizedfor eachPartmaynotexceedthe last grantaward issuedduring thereportingperiod; therefore transfersmaynot beincluded untilawarded byACL/AoA. ReporttotalStatePlanandAreaPlan Administrationallocated toallParts,totalfederalfundsauthorized foreachPart(enterthegrant awardas of the end ofthereportingperiodfor eachPart),andthe totalfor allParts.

StatePlanandAreaPlanAdministrationreportedin item10d istheamount oftheaward the granteeplans to allocatetowards administration,seebelowinformation onmaximumadministrationlimits:

StatePlanAdministration:OAA sections308(a)(1) and(b)(2) providetheauthorityforStatesto expend the greaterof5% oftheir totalallotment or$500,000forStatePlan

Administration/Administrativeactivities. InthecaseofGuam,AmericanSamoa,theUnitedStates

VirginIslands,theTrustTerritoryofthePacific Islands,andtheCommonwealth oftheNorthern

Mariana Islands,the greaterof5 percentofsuchallotment or$100,000. States which are Single Planning and Service Area States may use up to 5% or 10%, but not both, of their total Title III allotment for State Plan Administration.

AreaPlanAdministration:OAA sections304(d)(1)(A) and308(a)(3) provide the authorityfor

Statestoutilizeamaximumof10%statewideoftheir totalallotmentfor AreaPlanAdministration after theallocationoffundsforStatePlanadministration.TheallotmentforPartDmaybeincluded in the 10% computation,but no fundsmaybetaken fromPartD.

ITEM10.eFederalshareof expenditures:cumulative, identifiesthetotal Federalamount expendedfor eachPart. Completeall sectionswhere applicable.

NoFederaldollarsexpendedfor anyservicemayexceed theamountofFederaldollars allottedas ofthelast grant awardissuedduringthereporting periodforthePart.

Under PartBSupportiveServices,theamountrecordedshouldexcludeLTCOfunds, LTCOfunds shouldonlyberecordedonthe LTCOline. PartB Totallineis thesumofPartBAdministration, LTCO, andSupportiveServices.

AreaPlanAdministration maynot beallocatedtoPartD.

Under PartE, statesmaynotusemorethan 10% ofthetotalFederalandnon-Federalshare availableto thestateto provide supportservicestoolder relative caregivers.PartEshouldbebroken outto identifytheamountofFederalfunds expendedfor supportservicestoolderrelative caregivers. TheOlder Relative CaregiveramountshouldbeontheOlder Relative Caregiver Onlyline. Donotinclude Older Relative Caregiver Funds onthePartECaregiver Servicesline.PartE Totallineisthesum of PartE Administration,Older Relative CaregiverOnly, andCaregiver Services.

ITEM10.iTotalRecipientShareRequired:calculate theamount ofrecipientsharerequired basedonthe amount ofFederalExpendituresreported in10e. Therequiredrecipientshare foundinOAA sections304 and308and 45CFR 1321.47requireamatchfor State andAreaPlanadministration,PartB andC Services, andPartEServices.Complete allsectionswhere applicable. Seebelowinformationonrequiredmatch:

25% ofthetotal(Federal andRecipient)servicecostsfor State andAreaPlanAdministration

oExample:AFederalexpenditure of$100,000for StateandAreaPlanAdministration requiresarecipientshare of $33,333.

15% ofthetotal(Federal andRecipient) servicecostsfor PartB,C-1andC-2services

oOne third(1/3)oftherequired15%match forPartBandCservicesmustbe fromState sources.

oThe15%matchfor PartB SupportiveServices iscalculatedafter funds forLTCOhave beensetasidebytheState;thereis nomatchrequirementfor LTCOexpenditures.

Norecipientshareisrequiredfor III-D Services

25% ofthetotal(Federal andRecipient) servicecostsfor PartE services

ITEM10.jTotalrecipientshareof expenditures:reportthetotalnon-Federalamountexpended,the recipientshareof expenditures includescashandin-kindcontributions. Completeall sectionswhere applicable.

State fundedexpendituresshouldbe listed under theState column, evenif expenditures are made bytheNon-Stateentity

If matchisbeingpooledbetween partsB,C-1,C-2and/or E,indicatetheamountthatisbeing pooledin thecommentbox.

oMatch maybepooledbetweenPartsB,C-1 andC-2.

oExcessmatchinPartB,C-1, and/or C-2may be transferredto meetPartEmatch

requirements.

Under PartBSupportiveServices,theamountrecordedshouldexcludeLTCOfunds, LTCOfunds shouldonlyberecordedonthe LTCOline. PartB Totallineis thesumofPartBAdministration,

LTCO, andSupportiveServices.

TheOlder Relative CaregiveramountshouldbeontheOlder Relative Caregiver Only line. DonotincludeOlder Relative Caregiver Funds onthePartE CaregiverServices line. PartE Totalline isthesum ofPartE Administration, Older Relative CaregiverOnly, andCaregiver Services.

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Expires 11/30/2020