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Administration for Children and Families US Department of Health and Human Services

Administration for Children and Families, U.S. Department of Health and Human Services, SSBG Social Services Block Grant

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6e. SSBG REPORTING FORM

Click here for a Microsoft Excel version of the SSBG Reporting Form

Click here for a printer-friendly HTML version of the SSBG Reporting Form

ANNUAL REPORT OF SERVICES FUNDED BY THE
SOCIAL SERVICES BLOCK GRANT (SSBG)
FOR FISCAL YEAR:____________
     
  Contact: State:
  Title: Report Covers Period:
  Date:  
     

Service

Number of
Recipients

 

Expenditures

 

Provision
Method

Adults

C

Children

C

Total

 

Total $

C

SSBG $

C

SSBG $ Per Adult

SSBG $ Per Child

C

 

Public

Private

1

Adoption
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

Case
Management

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

Congregate
Meals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

Counseling
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

Day Care-
Adult

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

Day Care-
Children

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

Educ/Training
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

Employment
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

Family Planning
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

Foster Care
Services-Adults

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11

Foster Care
Services-Children

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12

Health Related
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13

Home Based
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14

Home Delivered
Meals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15

Housing
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16

Indep/Trans
Living Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17

Information
& Referral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18

Legal
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19

Pregnancy
& Parenting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20

Prevention
& Intervention

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21

Protective
Srvcs-Adults

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22

Protective
Srvcs-Children

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23

Recreation
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24

Residential
Treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25

Spec Srvcs-
Youth at Risk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26

Special Srvcs-
Disabled

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27

Substance Abuse
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28

Transportation
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29

Other
Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30

Other
Expenditures

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Transfers In
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Transfer Out
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Carry Forward
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Carry Over
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Administrative
Costs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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