SSBG_ Intended Use Plan_IUP Instructions

The Paperwork Reduction Act of 1995 (Pub. L. 104-13). STATEMENT OF PUBLIC BURDEN: Through this
information collection, ACF is identifying plans for state use of Social Services Block Grant (SSBG)
Funding.
The purpose of this information is to identify estimated SSBG expenditures and recipients, as well as the
intended geographic location and eligibility considerations for planned services. Information will be used
to gain insight on the administration of the SSBG program and to provide support to grantees related to
the administration of their SSBG program.
Public reporting burden for this collection of information is estimated to average 40 hours per response,
including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing
the collection of information. This is a mandatory collection of information and is required to retain a
benefit [45 C.F.R. §96.74.]. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of
1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0234 and the
expiration date is 05/31/2024. If you have any comments on this collection of information, please
contact the Office of Community Services, Social Services Block Grant Program via email:
SSBG@acf.hhs.gov.
Overview. States must use this form as the reporting instrument to satisfy the requirements of 45 CFR
96.74.
States are to report on their expenditures for and recipients of services within 29 service areas that are
defined in the Uniform Definitions of Services (https://www.acf.hhs.gov/ocs/resource/uniformdefinition-of-services ). If the State’s definition of a service differs from the Uniform Definitions, the
State should provide the State’s definition on the Intended Use Plan.
I.

General Information
1. State – Enter the State the reporting form is being submitted for.
2. Fiscal Year – Enter the fiscal year the report is being submitted for.
3. State Official Contact Information – Enter the name, title, agency, phone number, and email
address for the commissioner or director of the state’s lead SSBG agency.
4. SSBG Contact Information – Enter the name, title, agency, phone number, and email address for
the state’s chief administrator of the SSBG.
5. SSBG Award from Previous Year – Enter the total amount of the SSBG award from the previous
reporting period. Do not include amounts transferred or consolidated from other grant
programs.
6. SSBG Expenditures Planned for Current Year – Enter the total SSBG expenditures estimated for
the reporting period. Do not include SSBG funding that is being carried over from the previous
year. Do not include funds that will be consolidated or transferred from other grant programs.
7. TANF Funds Transferred into SSBG – Enter the total amount of funding transferred into SSBG
from Temporary Assistance for Needy Families program (TANF). Do not include TANF Transfer
Funding that is being carried over from a previous year.
8. Consolidated Block Grant Funds Included in SSBG Budget– Enter the total amount of funding
added to SSBG from the Consolidated Block Grant.
a. Funding Source(s) for the Consolidated Block Grant – Identify each funding source(s)
for the Consolidated Block Grant.

Amount of Funding from Each Program – Enter the amount of funding that relates to
each program being consolidated.
9. SSBG Carryover Funding from the Previous Year – Enter yes if the State has unobligated funding
from the previous year’s SSBG budget. Include TANF Transfer and amounts from the
Consolidated Block Grant.
a. Source(s) of Carryover Funding – Enter the program(s) that initially awarded the funds
that are being carried over from the previous fiscal year (ex. SSBG, TANF, Consolidated
Block Grant).
b. Amount of Carryover from Each Source – Enter the amount of carryover funding from
the previous fiscal year that relates to each program identified to have carryover
funding.
II. Administrative Operations
1. Administering Agency – Identify the agency designated to administer the state’s SSBG program.
2. Location – Identify the address of the agency designated to administer the state’s SSBG
program.
3. Mission/Goals of Agency – Outline the mission, goals and objectives, of the agency designated
to administer the state’s SSBG program.
4. Description of Financial Operations Systems – Describe the state’s process for calculating and
assigning costs (e.g., cost allocation plan). Describe the method of tracking and reconciling
expenditures.
III. Program Planning
1. Planning for Distribution and Use of Funds – Describe the planning process for determining the
state’s use and distribution of SSBG funds.
2. Describe the Characteristics of Individuals to be Served. Include definitions for child, adult, and
family; eligibility criteria; and income guidelines.
3. Public Inspection of Pre-Expenditure Report – Describe and provide documentation on how the
state made available for public inspection and comment the current Pre-Expenditure Report or
revision to the report. States are encouraged to use the form for the Post-Expenditure Report
(OMB # 0970-0234) to complete the Pre-Expenditure Report.
IV. Program Operations
b.

Complete one chart for each service category provided by the state during the reporting period.
1. Service Category (use uniform definition) – Enter the service supported with SSBG
expenditure using SSBG’s Uniform Definition of Services.
(https://www.acf.hhs.gov/ocs/resource/uniform-definition-of-services). In cases where no fit
is possible between the state-defined services and the Uniform Definitions of Services, use
item 29 “Other Services”.
2. SSBG Goal – Enter the SSBG goal that aligns with the service category.
3. Description of Services – Describe the services and activities to be provided using SSBG funds
under this service category.
4. Description of Recipients (eligibility considerations) – If applicable, describe the eligibility
criteria required for recipients to receive services under this category. Include income
guidelines, age, geographic boundaries, etc.

5. Method of Delivery and Geographic Area – Identify the geographic area/location where
services will be provided. Location should include the following information, when available:
address, Census block, Census Tract, Zip code, and county.
6. Partnering State Agency – Identify the state entities that are allocated SSBG funds to provide
services under the identified service category.
7. Sub Grantee/ Service Providers – When available, identify sub grantees and service providers
that are allocated SSBG funds to provide services under the identified service category.
Include the address for each entity identified.
V. Appendices
Appendix A: Documentation of Public Hearing
Attach documentation of public hearing, such as public hearing notices, letters, newspaper articles, etc.

Appendix B: Certifications
Attach signed copies of the following certifications
1.
2.
3.
4.

Drug-Free Workplace Requirements
Environmental Tobacco Smoke
Lobbying
Debarment, Suspension and Other Responsibility Matters

Appendix C: Proof of Audit
Federal regulations state that: “Each State shall, not less often than every two years, audit its
expenditures from amounts received (or transferred for use) under this title…Within 30 days following
the completion of each audit, the State shall submit a copy of that audit to the legislature of the State
and to the Secretary.” (Sec. 2006 [42 U.S.C. 1397a, Sec. 2006]). Provide a copy or link to the most recent
audit, or a description of the audit that specifies when the audit occurred and summarizes the results of
the audit.
Appendix D: SF 424M
Appendix E: Federal Financial Report (FFR) Form SF-425 (Scanned copy must be uploaded with the
Intended Use Plan)
Appendix F: ACF-196R (TANF) (Scanned copy must be uploaded with application)