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FINANCIAL STATUS REPORT - AOA SUPPLEMENTAL FORM TO SF-269-TITLE III

FINANCIAL STATUS REPORT

OMB NO. 0985-0004

AOA SUPPLEMENTAL FORM TO SF-269-TITLE III

Expires 08/31/2004

STATE______________

 FY__________________

DATE SUBMITTED_____________________ 

REPORTING PERIOD ENDED________________

Item 10 i Column III, Total Recipient Share of Outlays which consist of outlays from:

 

State 

AAAs

ADMIN 

$____________________________

$________________________

Title III

   

Part B

$____________________________

$________________________

LTCO (Part B) 

$____________________________

$________________________

Part C-1

$____________________________

$________________________

Part C-2

$____________________________

$________________________

Part D

$____________________________

$________________________

Part E 

$____________________________

$________________________

TOTAL 

$____________________________

$________________________

Item 10 j Column III, Federal Share of Net Outlays:

 

State 

AAAs

ADMIN 

$____________________________

$________________________

Title III

   

Part B

$____________________________

$________________________

LTCO (Part B) 

$____________________________

$________________________

Part C-1

$____________________________

$________________________

Part C-2

$____________________________

$________________________

Part D

$____________________________

$________________________

Part E 

$____________________________

$________________________

TOTAL 

$____________________________

$________________________

Item 10 o Column III Total Federal Funds Authorized by AOA for the Federal FY__________ have been allocated by the State as follows (as applicable):

1. State administrative activities which consists of funds in the amount of $________________ from the following:

Part B $_______________________

Part C-1 $_______________________

Part C-2 $_______________________

Part D $_______________________

Part E $_______________________

2. Part B, Supportive Services 

$___________________ 

   

3. Part B, Long Term Care Ombudsman 

$___________________ 

FY'2000 

$__________________

4. Part C-1, Congregate Meals

$___________________

   

5. Part C-2, Home Delivered Meals

$___________________

   

6. Part D, Preventive Health

$___________________

   

7. Part E, Caregivers 

$___________________

   

Area Plan Administration $____________________
which consists of funds from:

Part B     $_________________

Part C-1 $_________________

Part C-2 $_________________

Part E     $_________________

Item 10 p Column III, Unobligated Funds:

Part B

 $____________________

Part D

 $____________________

Part C-1

 $____________________

Part E

 $____________________

Part C-2

 $____________________

   

Item 10 r Column III, Disbursed Program Income using the additional alternative (cumulative amount):

Part B

  $____________________

Part D

  $____________________

Part C-1

  $____________________

Part E

  $____________________

Part C-2

  $____________________

   


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