Form 1 CSBG Eligible Entity List 2.1

OMB Control No: 0970-0382

Expiration date: XX/XX/XXXX

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13): Through this information collection, ACF is gathering information about planned activities related to and funded by CSBG for the upcoming fiscal year. Public reporting burden for this collection of information is estimated to average 2 hours per grantee, 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 (Sec. 676, Pub. L. 105-285, 112 Stat. 2735 (42 U.S.C. § 9908)). 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 0970-0382 and the expiration date is 06/30/2024. If you have any comments on this collection of information, please contact M. Monique Alcantara at melania.alcantara@acf.hhs.gov.

Community Services Block Grant (CSBG)

Model State Plan

Eligible Entities List

The following is a listing of all CSBG Eligible Entities within your state. This should include all eligible entities that receive funding under the “not less than 90% funds” of your CSBG Allocation. This information will be used to complete questions regarding your eligible entities within the State Plan and Annual Report. As well as be used as a tracking tool in the case that the name of an entity changes, there are designations or re-designations, terminations or reductions, or mergers.

Do not include entities that only receive remainder/discretionary funds from the state or tribes/tribal organizations that receive direct funding from OCS under Section 677 of the CSBG Act.

GUIDANCE: Under Type of Entity, select more than one type by holding down the CTRL key while making selections.

Note: Whether nonprofit or public, entities that receive CSBG funds are generally considered to be Community Action Agencies for the purpose of administering CSBG. The only specific exceptions outlined in the CSBG Act are Limited Purpose Agencies, Migrant and Seasonal Farmworker organizations, and Tribes and Tribal Organizations

Instructional Note: Limited Purpose Agency refers to an eligible entity that was designated as a limited purpose agency under Title II of the Economic Opportunity Act of 1964 for fiscal year 1981, that served the general purposes of a community action agency under Title II of the Economic Opportunity Act, that did not lose its designation as a limited purpose agency under Title II of the Economic Opportunity Act as a result of failure to comply with that Act and that has not lost its designation as an eligible entity under the CSBG Act.

Instructional Note: 90 percent funds are the funds a state provides to eligible entities to carry out the purposes of the CSBG Act, as described under Section 675C of the CSBG Act. A state must provide “no less than 90 percent” of their CSBG allocation, under Section 675B, to the eligible entities.

DUNS #

Unique Entity Identifier

CSBG Eligible Entity Official Name

CSBG Eligible Entity DBA

CSBG Eligible Entity Executive Director

Official Address

CSBG Eligible Entity Website Address

Geographical Area

Public or Non-profit

Type of Entity

Street Address

City

State

Zip Code

Provide the entity DUNS #. Do not include dashes. [READ ONLY]

This unique number is assigned to all entities who must register to do business with the federal government in SAM.gov. [REQUIRED, Numeric field, 12 characters]

Provide the official name of the CBSG Eligible Entity as registered with the DUNS. Note: This information will populate CSP Tables 5.1., 7.2., and 10.1. [REQUIRED Narrative, 500 characters]

Provide the “doing-business-as” name of the CSBG Eligible Entity, if different from the agency’s official name. If no dba, leave blank. [OPTIONAL Narrative, 500 characters]

Provide the name of the highest ranking official at the agency. [REQUIRED Narrative, 150 characters]

Provide the official street address of the CSBG Eligible Entity. [REQUIRED Narrative, 250 characters]

Provide the official city of the CSBG Eligible Entity. [REQUIRED Narrative, 50 characters]

Provide the official street address of the CSBG Eligible Entity. [REQUIRED Dropdown: 50 states, plus American Samoa, District of Columbia, Guam, Northern Mariana Islands, Puerto Rico, and U.S. Virgin Islands]

Provide the official zip code of the CSBG Eligible Entity. [REQUIRED Numerical Response, 5 digits]

Provide the web address for the agency. [REQUIRED Narrative, 200 characters]

Provide the counties, cities, areas that the CSBG Eligible Entity services. [REQUIRED Narrative, 250 characters]

Select Public or Non-profit [REQUIRED Dropdown: Public Non-Profit]

Select the type of entity [REQUIRED Dropdown: Community Action Agency Limited Purpose Agency Migrant or Seasonal Farmworker Tribe or Tribal Organization]