OMB # 0985-0009

exp. 11/30/2020

**Instructions for Completing the Certification of Long-Term Care Ombudsman Program Expenditures**

**FFY2019 Base Year Reporting**

States are to report base year Federal Fiscal Year  (FFY) 2019 expenditures   (10/1/2018-9/30/2019)

Expenditures means charges made by a non-Federal entity to a project or program for which a Federal award was received.[footnoteRef:1] [1:  Title 45: PUBLIC WELFARE PART 75—UNIFORM ADMINISTRATIVE REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR HHS AWARDS] 

Expenditures of the following funds are subject to minimum funding requirements in the Older Americans Act (2020 Authorization). FY ______ expenditures must have met or exceeded these amounts.

Title VII, Chapter 2, Ombudsman

· Report the amount that was EXPENDED on the Long Term Care Ombudsman program by the State, Local, Subgrantees, and/or Contractors of funds received under Title VII, Chapter 2 Long Term Care Ombudsman for the period 10/1/2018-9/30/2019  

· Do not include other cash or in-kind contributions or match

· Do not include program income

· Note: all Title VII, Chapter 2, Ombudsman funds must be expended on the Long Term Care Ombudsman program

Title VII, Chapter 3, Abuse Prev.

· Report the amount that was EXPENDED on the Long Term Care Ombudsman program by the State, Local, Subgrantees, and/or Contractors of funds received under Title VII Chapter 3, Elder Abuse and Prevention for the period 10/1/2018-9/30/2019  

· Do not include other cash or in-kind contributions or match

· Do not include program income

Title III, expended by State, as authorized in OAA, Sec.304(d)(1)(B)	

· Report the amount EXPENDED on the Long Term Care Ombudsman program by the State, Subgrantees, and/or Contractors other than AAAs and/or funds passed through to the AAAs of funds received under Title III Part B for the period 10/1/2018-9/30/2019

· Do not include other cash or in-kind contributions or match

· Do not include program income

Title III provided at AAA level

· Report the amount EXPENDED on the Long Term Care Ombudsman program by all Area Agencies on Aging within the State of funds received under Title III Part B for the period 10/1/2018-9/30/2019

· Do not include cash or in-kind contributions or match

· Do not include program income

· Note: the State should ensure, through the Area Plan and/or other processes, that AAAs are meeting the previous minimum funding level

Report other sources of funds expended, minimum funding does not apply

Other Federal

· Report the amount EXPENDED on the Long Term Care Ombudsman program by State, Area Agencies on Aging, Local, Subgrantees, and/or Contractors from other federal funds for the period 10/1/2018-9/30/2019 including, but not limited to Medicaid, Social Services Block Grant, Community Development Block Grant, etc.  

· Include all Other Federal sources of cash match or contributions

·  Do not include non-Federal expenditures such as State/Local cash, in-kind contributions, and/or match

· Do not include program income

State funds

· Report the amount EXPENDED by State, Area Agencies on Aging, Subgrantees and/or Contractors on the Long Term Care Ombudsman program with State funds for the period 10/1/2018-9/30/2019 including, but not limited to; State General Revenue Funds, State Revolving Funds, State Dedicated Funds, State fee or tax, Civil Monetary Penalties, etc.

· Include all State sources of cash contributions and/or cash match 

· Do not include in-kind contributions or in-kind match

· Do not include program income

Local funds

· Report the amount EXPENDED by Area Agencies on Aging and their Subgrantees and/or Contractors on the Long Term Care Ombudsman program with Local funds for the period 10/1/2018-9/30/2019 including, but not limited to; Local General Revenue Funds, Local Revolving Funds, Local Dedicated Funds, private grants, Fundraising Revenues, etc.

· Include all Local sources of cash contributions and/or cash match

· Do not include in-kind contributions or in-kind match

· Do not include program income

**Future Certifications**

Each year ACL will notify the State Unit on Aging (SUA) Director requesting certification of expenditures. Please send the signed certification for the preceding fiscal year expenditures as indicated in the notification.

1Public 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 0985-0009).  Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information.