| 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 |
$____________________ |
|
|