PROGRAM INSTRUCTION 

AoA - PI - 11 - 01 

TO: STATE AGENCIES ADMINISTERING PLANS UNDER TITLE III OF THE 

OLDER AMERICANS ACT OF 1965, AS AMENDED 

SUBJECT: AoA Supplemental Form to the SF-425 Report for Formula Grants Under Title III 

of the Older Americans Act. 

LEGAL AND RELATED 

REFERENCES: Older Americans Act Amendments, 2006 

The purpose of this Program Instruction is to inform the States of the revised AoA Supplemental Form to the 

SF-425 and to transmit a copy with instructions for completion. 

On December 20, 2010, OMB extended approval of the use of the AoA Supplemental Form to the SF-425 

which was published for comment in the July 21, 2010, and October 14, 2010, issues of the Federal Register. 

The approved form contains some revisions from the previously approved form, but they are not considered 

material changes. A copy of this supplemental form with instructions on completing the supplemental form is 

attached. This revised form replaces the AoA supplemental form currently in use and must now be used in 

reporting all open Title III grant years. States should duplicate the supplemental form for future use. The 

SF-425 can be found at http://www.whitehouse.gov/omb/grants forms/, along with a set of comprehensive 

instructions. AoA has also taken the liberty to provide a cross walk between the SF-269 and SF-425 (see 

attachment). 

The effective date for using the revised supplemental form is the first financial reporting period for FY 2011 

(October 1, 2010 to March 31, 2011). 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 all previous instructions regarding the use of AoA Supplemental Forms to the SF-425. 

ATTACHMENTS : AoA Supplemental Form to the SF-425, Instructions, and Crosswalk 

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

Regional Offices. 

__________________________________________ 

 Edwin Walker

 U.S. Deputy Assistant Secretary, Center for Program Operations 

Administration on Aging 
 

 

 

 

 

 

 

 

FEDERAL FINANCIAL REPORT (FFR) SF-425 

AOA SUPPLEMENTAL FORM TO SF-425-TITLE III 

STATE: _____________________ FY: _____________________ 

DATE SUBMITTED: _____________________ REPORTING PERIOD ENDED: _____________________ 

Item 10 d. Column III Total Federal Funds Authorized by AOA for the Federal FY__________ has 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 e. Column III, Federal Share of Expenditures: 

State Non-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 $_________________________ $________________________ 

SF-425-TITLE III – Non-Discretionary Rev 12/20/2010 

OMB No. 0985-0004 

Expires 11/30/2013 
 

 

 

 

 

 

TOTAL $_________________________ $________________________ 

Item 10 h. Column III, Unobligated Balance of Federal Funds: 

Part B $____________________ Part D $____________________ 

Part C-1 $____________________ Part E $____________________ 

Part C-2 $____________________ 

Item 10 j. Column III, Total Recipient Share of Expenditures which consists of outlays from: 

State Non-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 n. Column III, Program Income expended in accordance with the Addition Alternative (cumulative amount): 

Part B $____________________ Part D $____________________ 

Part C-1 $____________________ Part E $____________________ 

Part C-2 $____________________ 

SF-425-TITLE III – Non-Discretionary Rev 12/20/2010 

OMB No. 0985-0004 

Expires 11/30/2013 
 

 

 

 

THE ADMINISTRATION ON AGING (AoA) 

ADDITIONAL INSTRUCTIONS FOR COMPLETING 

FEDERAL FINANCIAL REPORT AND SUPPLEMENTAL FORM TO SF-425 

General Instructions 

1) The supplemental form must be submitted with the SF-425. 

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

3) Leave blank items l, m, and o, since the Deductive and the Matching or Cost Sharing alternatives are not allowed. 

4) The amount reported in item 10.i should also represent recipient share (i.e. those non-Federal resources contributed by AAA's, 

nutrition and service providers, etc.); break out accordingly. 

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.j should represent outlays made from recipient share of expenditures, broken out accordingly. 

7) Item 10.f should include the total Federal share of unliquidated obligations. 

8) Please note that program income used in accordance with the Addition Alternative (Item 10.n) is a Cumulative Amount and 

should be reported in 10n only. Program income should not be reported as Recipient or Federal share expenditures. 

9) Program income must be reported on the SF-425 for the fiscal year in which it is received. 

10)	 In Item 13, all 5 blocks should be completed--printed signature, written signature, telephone number, email address, 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-425. 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.d, 

Area Plan Administration. 

ITEM 10.d Total Federal funds authorized for this funding period 

The break down of Item 10.d should be the State's allocation of Federal funds for the following program functions in the indicated 

sections of the supplemental form. SF-425 reports as of September 30, XXXX (insert current FFY) 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.d must show the same amounts as the final Statement of Grant award for that FFY. If Item 10.d 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 

SF-425-TITLE III – Non-Discretionary Rev 12/20/2010 

OMB No. 0985-0004 

Expires 11/30/2013 
 

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.e Federal share of expenditures 

Item 10.e, cumulative column, identifies 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.h Unobligated balance of Federal 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.j Total recipient share of expenditures 

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 may 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.j, the cumulative column identifies 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.n Program income expended in accordance with the Addition Alternative 

Breakdown the cumulative amount of program income disbursed by Part/Subpart. Disbursed program income must be reported on the 

SF-425 for the fiscal year in which the program income was earned (45 CFR Part 92.21(f)(2)). 

SF-425-TITLE III – Non-Discretionary Rev 12/20/2010 

OMB No. 0985-0004 

Expires 11/30/2013 
Attachment 

Crosswalk between SF-425 and SF-269 

2/23/2011 

SF-425 Remarks SF-269 Remarks 

1. Federal Agency and Organizational 

Element to Which Report is Submitted 

data entry 1. Federal Agency and Organizational 

Element to Which Report is Submitted 

data entry 

2. Federal Grant or Other Identifying 

Number Assigned by Federal Agency (To 

report multiple grants, use FFR 

Attachment) 

data entry 2. Federal Grant or Other Identifying 

Number Assigned By Federal Agency 

data entry 

3. Recipient Organization (Name and 

complete address including Zip code) 

data entry 3. Recipient Organization (Name and 

complete address, including ZIP code) 

data entry 

4a. DUNS Number data entry 

4b. EIN data entry 4. Employer Identification Number data entry 

5. Recipient Account Number or 

Identifying Number (To report multiple 

grants, use FFR Attachment) 

data entry 5. Recipient Account Number or 

Identifying Number 

data entry 

6. Report Type: 

Quarterly 

Semi-Annual 

Annual 

Final 

choice of 

"Quarterly", 

"Semi-Annual", 

"Annual", or 

"Final" 

6. Final Report 

Yes 

No 

choice of "Yes" 

or "No" 

7. Basis of Accounting: 

Cash 

Accrual 

choice of 

"Cash" or 

"Accrual" 

7. Basis 

Cash 

Accrual 

choice of 

"Cash" or 

"Accrual" 

8. Funding/Grant Period 

From: (month, Day, Year) 

To: (Month, Day, Year) 

data entry 8. Funding/Grant Period (See instructions) 

From: (month, Day, Year) 

To: (Month, Day, Year) 

data entry 

9. Reporting Period End Date (Month, 

Day, Year) 

data entry 9. Period Covered by this Report 

From: (Month, Day, Year) 

To: (Month, Day, Year) 

data entry 

10. Transactions 

Federal Cash: 

10a. Cash Receipts data entry for 

Federal Cash 

10b. Cash Disbursements data entry for 

Federal Cash 

10c. Cash on Hand (line a minus b) data entry for 

Federal Cash 

Federal Expenditures and Unobligated 

Balance: 

10d. Total Federal funds authorized data entry 10o. Total Federal Funds Authorized for 

this funding period 

data entry 

10e. Federal share of expenditures data entry 10j. Federal share of net outlays (line d 

less than i) 

calculated 

10f. Federal share of unliquidated 

obligations 

data entry 10m. Federal share of unliquidated 

obligations 

data entry 

10g. Total Federal share (sum of Lines e 

and f) 

calculated 10n. Total Federal Share (j+m) calculated 

10h. Unobligated balance of Federal funds 

(line d minus g) 

calculated 10p. Unobligated balance of Federal 

Funds (line o-n) 

calculated 

Recipient Share: 

10i. Total recipient share required data entry 

10j. Recipient share of expenditures data entry 10i. Total recipient share of net outlay 

(e+f+g+h) 

calculated 

10k. Remaining recipient share to be 

provided (line I minus j) 

calculated 

Page 1 of 2 
Attachment 

Crosswalk between SF-425 and SF-269 

2/23/2011 

SF-425 Remarks SF-269 Remarks 

Program Income: 

10l. Total Federal program income earned data entry 10t. Total program income realized (Q + 

R + S) 

calculated 

10m. Program income expended in 

accordance with the deduction alternative 

always 0 10c. Progam income used with the 

deduction alternative. 

always 0 

10n. Program income expended in 

accordance with the addition alternative 

data entry 10r. Disbursed program income using the 

addition alternative 

data entry 

10o. Unexpended program income (line l 

minus line m or line n) 

calculated 10s. Undisbursed program income data entry 

10a. Total Outlays data entry 

10b. Refunds, rebates, etc data entry 

10d. Net Outlays (line a, less than b + c) calculated 

10e. Third Party (in kind) contributions data entry 

10f. Other Fed awards authorized to 

match this award. 

data entry 

10g. Program income used with 

matching cost sharing alternative 

data entry 

10h. All other recipient outlays not shown 

on e,f or g 

data entry 

10k. Total unliquidated obligations data entry 

10l. Recipients share of unliquidated 

obligations 

data entry 

10q. Disbursed program income shown 

on lines c and g 

data entry 

11. Indirect Expense 

11a. Type 

Provisional 

Predetermined 

Final 

Fixed 

data entry 11a.Type of Rate 

Provisional 

Predetermined 

Final 

Fixed 

place "X" in the 

appropriate 

box 

11b. Rate data entry, or 

leave blank 

11b. Rate data entry, or 

leave blank 

11c. Period From/To data entry, or 

leave blank 

11d. Base data entry, or 

leave blank 

11c. Base data entry, or 

leave blank 

11e. Amount Charged data entry, or 

leave blank 

11d. Total Amount data entry, or 

leave blank 

11f. Federal Share data entry, or 

leave blank 

11e. Federal Share data entry, or 

leave blank 

11g. Total Base 

Total Amount Charged 

Total Federal Share 

data entry, or 

leave blank 

12. Remarks data entry 12. Remarks data entry 

13. Certification: 

13a. Typed or Printed Name and Title of 

Authorized Certifying Official 

data entry Typed of Printed Name and Title data entry 

13b. Signature of Authorized Certifying 

Official 

signature 

required 

Signature of Authorized Certifying Official signature 

required 

13c. Telephone (Area code, number and 

extension) 

data entry Telephone (Area code, number and 

extension) 

data entry 

13d. Email address data entry 

13e. Date Report Submitted data entry Date Report Submitted data entry 

Page 2 of 2