**DEPARTMENT OF HEALTH & HUMAN SERVICES**Administration on Aging

Center for Policy and Management

One Massachusetts Ave., NW

Room 4602

Washington, DC 20001

**PROGRAM INSTRUCTION**

AoA - PI - 08 – 05

TO:STATE AGENCIES ADMINISTERING PLANS UNDER TITLE III OF THE OLDER AMERICANS ACT OF 1965, AS AMENDED

SUBJECT:AoA Supplemental Form to the SF-269 Report for Formula Grants Under Title III of the Older Americans Act.

LEGAL AND RELATED

REFERENCES:Older Americans Act Amendments, 2008

The purpose of this Program Instruction is to inform the States of the revised AoA Supplemental Form to the SF-269 and to transmit a copy with instructions for completion.

On November 2, 2007, OMB extended approval of the use of the AoA Supplemental Form to the SF-269 which was published for comment in the May 24, 2007 issue of the FederalRegister.  The approved form contains some minor revisions from the previously approved form, but no material changes.  A copy of this supplemental form with instructions on completing both the SF-269 and the supplemental form is attached.  This revised supplemental form replaces the AoA supplemental form currently in use and must now be used and must accompany the SF-269 in reporting all open Title III grant years.  States should duplicate the supplemental form for future use.  The SF-269 can be found at http://www.whitehouse.gov/omb/grants.

The effective date for using the revised supplemental form is the second financial reporting period for FY 2008 (April 1, 2008 to September 30, 2008).   There is no change to the frequency of reporting or the due dates for receipt in the Regional Offices.  Reporting for the first six months of a fiscal year (October 1- March 31) is due in the Regional Office by April 30.  Reporting for the second six months of a fiscal year (April 1 - September 30) is due in the Regional Office by October 30.  All open grant years will be reported on this schedule until all obligations are liquidated within the allowable two year period following the year of the awarding of the grant.  Grants awarded with realloted funds have an additional year for obligation liquidation.  All reporting must be completed on an accrual basis.

This supersedes AoA-PI-02-01 and all previous instructions regarding the use of AoA Supplemental Forms to the SF-269.

ATTACHMENTS:AoA Supplemental Form to the SF-269 and Instructions

INQUIRIES:Inquiries should be addressed to the Regional Administrators for Aging, DHHS Regional Offices.

__________________________________________

John Wren

Deputy Assistant Secretary for Policy & Management

FINANCIAL STATUS REPORT

AOA SUPPLEMENTAL FORM TO SF-269-TITLE III

STATE______________               FY__________________

DATE SUBMITTED_____________________REPORTING PERIOD ENDED________________

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

StateNon-State

ADMIN$_________________________$________________________

Title III

Part B (Excluding LTCO Funds)$_________________________$________________________

LTCO (Part B) Only$_________________________ $________________________

Part C-1$_________________________$________________________

Part C-2$_________________________$________________________

Part D$_________________________$________________________

Part E (Including Grandparent Funds)$_________________________$________________________

Grandparent Only$_________________________$________________________

TOTAL$_________________________$________________________

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

StateNon-State

ADMIN$_________________________$________________________

Title III

Part B (Excluding LTCO Funds)$_________________________$________________________

LTCO (Part B) Only$_________________________ $________________________

Part C-1$_________________________$________________________

Part C-2$_________________________$________________________

Part D$_________________________$________________________

Part E (Including Grandparent Funds)$_________________________$________________________

Grandparent Only$_________________________$________________________

TOTAL$_________________________$________________________

OMB No. 0985-0004

Expires 11/30/2010

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 consist 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 (Including LTCO Funds)$____________________

3. Part B, Long Term Care Ombudsman Only            $____________________  FY2000_______________

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$____________________

**THE ADMINISTRATION ON AGING (AoA)**

**ADDITIONAL INSTRUCTIONS FOR COMPLETING**

**FINANCIAL STATUS REPORT**

**AND**

**SUPPLEMENTAL FORM TO SF-269**

**General Instructions**

1)The supplemental form must be submitted with the SF-269.

2)All amounts reported should be rounded off to the nearest dollar; no cents should be reported.  

3)Leave blank items 10.c and 10.g since the Deductive and the Matching or Cost Sharing alternatives are not allowed. 

4)The amount reported in item 10.e should represent non-State, subrecipient contributions (i.e. those non-Federal resources contributed by AAA's, nutrition and service providers, etc.).  

5) Voluntary contributions are program income, as defined at 45 CFR Part 92.25(b).  **In addition**, 45 CFR Part 92.21(f) requires that voluntary contributions, as program income, must be disbursed before any further Federal funds are requested.

6)The amount reported in item 10.h should represent those outlays made from State resources only.

7)Item 10.k should include the total Federal and State share of unliquidated obligations.  These would include State funds awarded to subrecipients (AAA's, etc.) which have not been earned/expended.

8)Item 10.l, the State and subrecipient’s share from 10.k above. 

9)Please note that program income used in accordance with the Additional Alternative (Item 10.r) is a CUMULATIVE AMOUNT and should not be included in the total outlays on line 10. 

10) Program income **MUST** be reported on the SF-269 for the fiscal year in which it is received. a.

11)In Item 13, all 4 blocks should be completed--printed signature, written signature, telephone number, and date.

Since the current form does not have multiple columns for reporting more than one program function, State Agencies are required to break down the following items on the Supplemental Form to the SF 269.  States which are a Single State Planning and Service Area and do not have Area Agencies on Aging (AAA) are also required to complete the AoA Supplemental Form with each submission.  This includes all lines and columns, except where a line is specifically designated for an Area Agency on Aging (AAA), such as Item 10.o, Area Plan Administration.

**ITEM 10.i  Total recipient share of net outlays.**

Sections 304 and 308 of the Older Americans Act and Section 1321.47 of the Title III regulations require a match for State and Area Plan administration, Part B and C Services, and Part E Services.  Federal expenditures for State and Area Plan Administration, and Federal expenditures for Part E, may not exceed 75% of Total expenditures, and Federal expenditures for Parts B and C my not exceed 85% of Total expenditures.  Match for State and Area Plan Administration may be pooled. Match for Parts B and C may be pooled.  No match is required for Part D.  In Item 10.i, Column III, identify the total **non-Federal** amount expended for State and Area Plan Administration on the first (ADMIN) line.  Break out the remaining non-Federal share of outlays in the spaces provided for each program service.

· Under Part B, because the 15% match is calculated after funds for LTCO have been set aside by the State, the amount recorded should exclude LTCO (Part B) funds.  LTCO (Part B) funds should be recorded on the LTCO (Part B) Only line.

· Under Part E, states may not use more than 10% of the total Federal and non-Federal share available to the state to provide support services to grandparents and older individuals who are relative caregivers of a child who is not more than 18 years of age.  Part E should be broken out to identify the amount of non-Federal funds expended for support services to grandparents and relative caregivers.  The Grandparent amount should be included in the Part E line and recorded on the Grandparent line.

**ITEM 10.j  Federal share of net outlays.**

In  Item 10.j, Column III, identify the total **Federal** amount expended for State and Area Plan Administration on the first (ADMIN) line.  Break out the remaining Federal share of outlays in the spaces provided for each program service.

· No Federal dollars expended for any service may exceed the amount of Federal dollars allotted for that service on the last grant award following approval of transfers for that fiscal year.   If the amount reported for any service temporarily exceeds the Federal grant award due to pending approval of transfers for the fiscal year, please explain on Line 12.  

· Under Part B, the amount recorded should exclude LTCO (Part B) funds.  LTCO (Part B) funds should be recorded on the LTCO (Part B) Only line.

· Under Part E, states may not use more than 10% of the total Federal and non-Federal share available to the state to provide support services to grandparents and older individuals who are relative caregivers of a child who is not more than 18 years of age.  Part E should be broken out to identify the amount of Federal funds expended for support services to grandparents and relative caregivers.  The Grandparent amount should be included in the Part E line and recorded on the Grandparent line.

**ITEM 10.o  Total Federal funds authorized for this funding period.**

The break down of Item 10.o should be the State's allocation of Federal funds for the following program functions in the indicated sections of the supplemental form.  SF-269 reports as of September 30, 2008 should reflect allocations according to the transfer grant.

State Administration/Administrative Activities.

Sections 308(a)(1) and (b)(2) provide the authority for States to expend the greater of 5% of their total allotment or $500,000 for this function.  Provide the total amount of Title III funds used for State Administration on Line 1.  This total must be broken down further to identify the amount of funds utilized from each program allotment.  

Part B, Supportive Services; Part C1, Congregate Meals; and Part C2, Home Delivered Meals

Sections 308 (b)(4) and (5) provide the authority for States to transfer between Title III-B and III-C and Titles III-C1 and C2.  Provide the amount utilized by the State after transfers for each of the three program allotments on Lines 2, 4, and 5 respectively.  Part B Funds for the Long-Term Care Ombudsman program should also be included in Part B, Line 2.  A final grant award is issued to states by September 30th each year, the last day of the Federal Fiscal Year (FFY).  This reflects all transfers that have taken place in the state for that FFY.  These transfers may be between Title III-B and III-C and between Titles III-C1 and C2.  From September 30th forward, Item 10.o must show the same amounts as the final Statement of Grant award for that FFY.  If Item 10.o is allocating funds on the basis of transfers before the final transfer grant is issued, please state so in Line 12.

Long-Term Care Ombudsman

Sections 304(d)(1)(B) and 307(a)(9) provide the authority to utilize Part B funds for Long-Term Care Ombudsman services.  Provide the amount of Fiscal Year 2000, Title III-B funds utilized by the State for costs incurred by the State Agency in support of the Statewide Long-Term Care Ombudsman program. The total Federal funds authorized for this purpose must equal or exceed the amount spent in the base year 2000, and should be recorded on Line 3 and included in the Part B amount in Line 2 above.      

Part D, Disease Prevention and Health Promotion Services

Section 303(d) authorizes funds for grants under Part D.  Provide the amount of Title III

funds utilized for preventive health services on Line 6.

Part E, National Family Caregiver Support Program

Sections 303 (e)(1) and (2) authorize funds for grants under Part E.  Provide the amount of Title III funds utilized for caregiver services on Line 7.  Under Part E, states may not use more than 10% of the total Federal and non-Federal share available to the state to provide support services to grandparents and older individuals who are relative caregivers of a child who is not more than 18 years of age.

Area Plan Administration

Sections 304(d)(1)(A) and 308(a)(3) provide the authority for States to utilize a maximum of 10% statewide of their total allotment for Area Plan Administration after the allocation of funds for State plan administration.  This total must be broken down further to identify the amount of funds utilized from each program allotment.  The allotment for Part D may be included in the 10% computation, but no funds may be taken from Part D.

**ITEM 10.p  Unobligated funds**

Breakdown the total unobligated Federal funds by Part/Subpart.  If the report being submitted is a final report, please indicate in Line 12 if those funds **HAVE OR HAVE NOT** been drawn down from the Payment Management System (PMS).

**ITEM 10.r  Disbursed program income using the additional alternative.**

Breakdown the cumulative amount of program income disbursed by Part/Subpart.  Disbursed program income must be reported on the SF269 for the fiscal year in which the program income was earned (45 CFR Part 92.21(f)(2)).