OMB No. 0985-0007

Expiration Date:  04/30/2022

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number (OMB 0985-0007).  Public reporting burden for this collection of information is estimated to average 3.49 hours per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information.  The obligation to respond to this collection is required to retain or maintain benefits under the statutory authority 42 U.S. Code § 3057e.

# ADMINISTRATION FOR COMMUNITY LIVING

# ADMINISTRATION ON AGING

# TITLE VI PROGRAM PERFORMANCE REPORT

**Report Period April 1, [year] – March 31, [year]**

**Title VI, Parts A/B and C _______		Title VI, Part A/B only ______**

Grantee Name _____________________________________________________________

Telephone_______________________________ Email address__________________________

Part A/B Grant No. _________ Part C Grant No.__________

**------------------------------------------------------------------------------------------------------------------------------------------**

# 

# TITLE VI, PART A/B REPORT 

## A. STAFFING INFORMATION 

Enter the number of staff paid wholly or partly by Title VI, Part A/B funds. 

## 

### Full-time staff

## 

### Part-time staff

## 

## B. NUTRITION SERVICES

### Congregate Meals

### Home-Delivered Meals

### Other Nutrition Services

## C. SUPPORTIVE SERVICES

### Access Services

### In-home Services

### Other Supportive Services

Optional space for other supportive services offered that are not listed above (1500 words or less): 

## D. FINANCE

### Part A/B Spending

Optional explanation of elements included in total amount of funds (1500 words or less): 

### 

### 

### What other sources of funds help you support your Title VI services:

### 

*This finance section will be an addendum to the 425. This will NOT be used for audits.*

## E. STORYTELLING

Please share an example of how your Title VI program has helped an individual or your community (1500 words or less):

**OFFICIAL SIGNATURE** - If only completing Title VI, Part A/B of this report go to page [insert page] to sign and date.

# TITLE VI, PART C REPORT

## 

## A. STAFFING INFORMATION 

Enter the number of staff paid wholly or partly by Title VI, Part C funds. 

### Full-time staff

## 

### Part-time staff

## 

## B. TOTAL CAREGIVERS SERVED 

*Caregivers served by the Title VI program are informal, unpaid providers of in-home and community care. Caregivers may be family members, neighbors, friends, or others.*

## C. CAREGIVER SUPPORT SERVICES 

### Services for Caregivers

**Supplemental Services**: (report on units provided, unduplicated caregivers served, service category)

There will be a dropdown menu of service categories: **Home Modification/Repairs, Consumable Items, Lending Closet, Homemaker/Chore/Personal Care Service, Financial Support, Other**.

### Respite Care for Caregivers

*Respite care is a service for informal caregivers, not Elders or children. Respite care refers to allowing caregivers time away to do other activities by having an Elder, person with a disability, or child cared for by someone else.*

## D. FINANCE 

### Part C Spending

*This finance section will be an addendum to the 425. This will NOT be used for audits.*

Report Certified By ________________________________________________

(Tribal Official or other authorized personnel)

Report Prepared by: ____________________________________________________________

Telephone: _______________________________ Email address: _______________________

Date Submitted: _________________________________________________

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