CAN ALERT SFY-18 ALERT.PDF

Maricopa County — Formal (2017-05-10)

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Division of Aging and Adult Services
ALERT
SFY-18-A
Community Services Block Grant (CSBG)
for SFY-2018
State Fiscal Year (SFY) 2018 CSBG Discretionary Awards: The Division of Aging and Adult
Services (DAAS) is pleased to announce the CSBG Discretionary Special Project Fund awards
for SFY 2018 in the amount of $105,560 to the following CSBG eligible entities listed below:
CSBG Funds Discretionary Funds Special Projects
Agency Amount
Coconino County Community Services Department – $16,569
Collective Impact Initiative – collaborative project
City of Phoenix Human Services Department – Public $ 23,611
Information Delivery - equipment
Pima County Community Services Department $ 28,101
Arizona Community Action Association – Public $ 8,284
Information Delivery – website redevelopment
Mesa Community Action Network – Workforce $28,995
Opportunity Initiative – collaborative project
Total CSBG Discretionary Awarded $105,560
The total amount of awards was increased since agencies submitted Itemized Service Budgets
(ISBs) due to an increase in CSBG allocations. Agencies receiving awards are requested to
provide revised ISBs by March 30, 2017.
Discretionary funds must be fully expended by June 30, 2018.
Reporting for CSBG Discretionary Special Projects will consist of a brief narrative description of
activities and expenditures, accompanied by outcomes and the deployment status of any
equipment purchased with CSBG dollars. Each agency will use the Results Oriented
Management and Accountability/National Performance Indicators (ROMA/NPIs), as set forth in
the agency’s proposal and/or information request responses, to track outcomes. The outcomes
and a narrative description of activities and expenditures for Discretionary projects shall be
included in the new CSBG Annual Report that is due October 1, 2019. DAAS/CAPS will provide
assistance in reporting outcomes for these projects in the new CSBG Annual Report system
following the close of SFY 2018.
Should you have any questions, please contact your assigned Contract Specialist or CSBG
Program Specialist, Diana Gravett, at dgravett@azdes.gov or (602) 542-6594.

Division of Aging and Adult Services
ALERT
SFY-18-A1
Community Services Block Grant (CSBG)
for SFY 2018
The Division of Aging and Adult Services (DAAS) allocated $5,868,290 of CSBG funding for State
Fiscal Year (SFY) 2018. This amount is significantly higher than the SFY 2017 initial allocation, due to
an increase in the FFY 2016 grant that was not placed in the SFY 2017 contracts This causes a
“bubble” in the SFY 2018 funding that will result in a decrease for SFY 2019 if grant funding remains
the same. Following deliberations with the Network that led to an agreement on data sources and
funding factors to be used, beginning in SFY 2018 and going forward, the funding formula for CSBG
has been revised for SFY 2018 as follows:
Funds will be distributed based on the following factors: number of individuals at or below 125 percent
of the Federal Poverty Level, urban or rural status, individuals under 50 percent of the Federal Poverty
Level considered extreme poverty and a minimum funding variable. The sources used for the poverty
data were the 2015 Five year American Community Survey and the 2010 United States Census for the
rural factors, respectively.
Migrant/
Poverty Rural Extreme Tribal Seasonal Minimum Funding
Factor Factor Poverty Adjustment Farmworker Variable
Adjustment
90% 5% 5% Yes 2% $150,000
The unemployment factor has been removed; the poverty factor was increased from 85 percent to 90
percent, the extreme poverty factor of five percent was added, and the minimum funding variable
remained unchanged.
For SFY 2018, agencies were to be held harmless for 50 percent of reductions, if said reduction is
eight percent or greater. However, due to increased allocations, no eligible entities lost sufficient
funding to trigger the hold-harmless formula.
CSBG Funds are allocated to designated Community Action Agencies.
Agency Allocation
City of Glendale Community Action Program $232,350
City of Phoenix Human Services Department $1,609,418
Coconino County Community Services Department $150,000
Community Action Human Resources Agency $355,893
Gila County Division of Health and Community Services $150,000
Maricopa County Human Services Department $977,885
Mesa Community Action Network $361,063
Northern Arizona Council of Governments $305,074
Pima County Community Action Agency $887,354
Southeastern Arizona Community Action Program $225,162
Western Arizona Council of Governments $496,725
Subtotal
Portable Practical Educational Preparation, Inc. $117,366
Total $5,868,290

Division of Aging and Adult Services
ALERT
SFY-18-A1
Community Services Block Grant (CSBG)
for SFY 2018
Should you have any questions or require additional information, please contact your assigned
Contract Specialist.
No changes will be made to the following CSBG discretionary funds for SFY 2018. DAAS will be
working with Arizona Community Action Association to update and refine service deliverables to
meeting Network and Department of Economic Security (DES)/DAAS projected needs.
Agency Priority Area Allocation
Arizona Community Statewide Coordination, Training and $155,000
Action Association Technical Assistance Among Eligible
Entities and DES/DAAS
Total $155,000
Discretionary funds must be fully expended by June 30, 2018.
Should you have any questions or require additional information, please contact Tammy Frazee,
Community Action Program Administrator, at 602-542-2895.

CSBG
Community Action Network Funding Formula SFY 2018 SFY 18-A
Proposed Funding Components
Fund Source - CSBG (Funding $5,868,290)
5% 5% 2010 90% $150,000
census %
Funds Balance of of service $ Adjusted for
distributed Rural Distributed persons distributed % of Total Allocation Minimum $ 150,000 12 Month Revised 12
District Agency Served based on Population Based on Extreme Poverty @ or based on % of Total Using Rural and Funding Minimum Total FY 2018 Hold Month Total
urban or rural Internal Extreme below persons @ or Allocation Poverty Factors Variable Funding Allocation Harmless Allocation
status Percentage Poverty 125% of below 125% of Variable
poverty poverty
District 1 MesaCAN Maricopa/Mesa $ - 0.00% 6.45% $ 18,551 6.80% $ 351,734 6.31% $ 370,285 $ - $ 370,285 $ (9,222) $ 361,063 $ - 361,063.00
CITY OF GLENDALE Maricopa/Glendale $ - 0.00% 4.48% $ 12,892 4.35% $ 225,393 4.06% $ 238,285 $ - $ 238,285 $ (5,935) $ 232,350 $ - 232,350.00
CITY OF PHOENIX Maricopa/Phx $ - 0.00% 31.21% $ 89,757 30.15% $ 1,560,767 28.13% $ 1,650,524 $ - $ 1,650,524 $ (41,106) $ 1,609,418 $ - 1,609,418.00
MARICOPA COUNTY Maricopa/balance $ 13,067 4.54% 18.89% $ 54,317 18.07% $ 935,477 17.09% $ 1,002,861 $ - $ 1,002,861 $ (24,976) $ 977,885 $ - 977,885.00
District 2 PIMA COUNTY
Pima $ 10,328 3.59% 16.36% $ 47,052 16.47% $ 852,638 15.51% $ 910,018 $ - $ 910,018 $ (22,664) $ 887,354 $ - 887,354.00
District 3 COCONINO COUNTY
Coconino $ 19,015 6.61% 1.91% $ 5,505 1.74% $ 89,967 1.95% $ 114,487 $ 35,513 $ - $ - $ 150,000 $ - 150,000.00
NACOG Totals $ 52,356 $ 12,790 4.79% $ 247,720 5.33% $ 312,866 $ - $ 312,866 $ (7,792) $ 305,074 $ - 305,074.00
Apache $ 3,570 1.24% 0.25% $ 724 0.33% $ 16,891 $ 21,185 7% $ (528) $ 20,657 20,657.00
Yavapai $ 33,642 11.70% 2.78% $ 7,998 3.08% $ 159,176 $ 200,816 64% $ (5,001) $ 195,815 195,815.00
Navajo $ 15,144 5.27% 1.41% $ 4,068 1.38% $ 71,653 $ 90,865 29% $ (2,263) $ 88,602 88,602.00
District 4 WACOG Totals $ 85,595 $ 18,830 7.82% $ 404,987 8.68% $ 509,412 $ - $ 509,412 $ (12,687) $ 496,725 $ - 496,725.00
La Paz $ 4,090 1.42% 0.28% $ 808 0.37% $ 19,350 $ 24,248 5% $ (604) $ 23,644 23,644.00
Mohave $ 38,230 13.30% 3.22% $ 9,259 3.49% $ 180,882 $ 228,371 45% $ (5,688) $ 222,683 222,683.00
Yuma $ 43,275 15.05% 3.05% $ 8,763 3.96% $ 204,755 $ 256,793 50% $ (6,395) $ 250,398 250,398.00
District 5 CAHRA Pinal $ 60,780 21.14% 5.78% $ 16,619 5.56% $ 287,584 6.22% $ 364,983 $ - $ 364,983 $ (9,090) $ 355,893 $ - 355,893.00
GILA COUNTY
Gila $ 7,768 2.70% 0.61% $ 1,765 0.71% $ 36,757 0.79% $ 46,290 $ 103,710 $ - $ - $ 150,000 $ - 150,000.00
District 6 SEACAP Totals $ 38,637 $ 9,468 3.53% $ 182,808 3.93% $ 230,913 $ - $ 230,913 $ (5,751) $ 225,162 $ - 225,162.00
Cochise $ 21,200 7.37% 1.94% $ 5,587 1.94% $ 100,309 $ 127,096 55% $ (3,165) $ 123,931 123,931.00
Graham $ 4,795 1.67% 0.53% $ 1,514 0.44% $ 22,685 $ 28,994 13% $ (722) $ 28,272 28,272.00
Greenlee $ 1,442 0.50% 0.12% $ 340 0.13% $ 6,823 $ 8,605 4% $ (214) $ 8,391 8,391.00
Santa Cruz $ 11,200 3.89% 0.70% $ 2,027 1.02% $ 52,991 $ 66,218 29% $ (1,649) $ 64,569 64,569.00
Totals $ 287,546 100% 100% $ 287,546 100.00% $ 5,175,832 98.00% $ 5,750,924 $ 139,223 $ 5,590,147 $ (139,223) $ 5,750,924 $ - 5,750,924
PPEP 2.00% $ 117,366 $ 117,366 $ - 117,366
Totals 100.00% $ 5,868,290 $ 5,868,290 $ - $ 5,868,290
GRAND TOTALS $ 287,546.00 $ 287,546.00 $ 5,175,832.00 $ 5,868,290
$ 287,546.00 $ 287,546.00 $ 5,175,832.00
$ - $ - $ - $ - $ - $ -
PPEP 117,366.00 $ 117,366.00 $ 117,366.00
5% Rural 287,546.00 $ 287,546.00 $ 287,546.00
5% Extreme Poverty 287,546.00 $ 287,546.00 $ 287,546.00
90% Poverty 5,175,832.00 $ 5,175,832.00 $ 5,175,832.00
Total 5,868,290.00 5,868,290.00 5,868,290.00

CSBG Discretionary
SFY 2018
Community Action Network Funding Formula ALERT 18-A1
Proposed Funding Components
Fund Source - CSBG Discretionary (Funding $260,560)
FY 2018 Initial Increase/ FY 2018 Revised
District Agency Served
Allocation (Decrease) Allocation
District 1
MesaCAN
Maricopa/Mesa $ 28,995 $ - $ 28,995
CITY OF GLENDALE
Maricopa/Glendale $ - $ - $ -
CITY OF PHOENIX
Maricopa/Phx $ 23,611 $ - $ 23,611
MARICOPA COUNTY
Maricopa/balance $ - $ - $ -
District 2
PIMA COUNTY
Pima $ 28,101 $ - $ 28,101
District 3
COCONINO COUNTY
Coconino $ 16,569 $ - $ 16,569
NACOG Totals $ - $ - $ -
Apache $ - $ - $ -
Yavapai $ - $ - $ -
Navajo $ - $ - $ -
District 4
WACOG Totals $ - $ - $ -
La Paz $ - $ - $ -
Mohave $ - $ - $ -
Yuma $ - $ - $ -
District 5
CAHRA
Pinal $ - $ - $ -
GILA COUNTY
Gila $ - $ - $ -
District 6
SEACAP Totals $ - $ - $ -
Cochise $ - $ - $ -
Graham $ - $ - $ -
Greenlee $ - $ - $ -
Santa Cruz $ - $ - $ -
Statewide
ACAA Statewide $ 163,284 $ - $ 163,284
Totals $ 260,560 $ - $ 260,560
FY 2018 Total Allocated $ 260,560

Division of Aging and Adult Services
ALERT
SFY-18-B
Low Income Home Energy Assistance Program (LIHEAP)
for SFY 2018
The Division of Aging and Adult Services (DAAS) allocated $18,542,309 of LIHEAP funding for State
Fiscal Year (SFY) 2018. This amount is significantly lower than the SFY 2017 initial allocation, due to a
decrease in the FFY 2016 grant that was received late and not placed in the SFY 2017 contracts, as
requested by the CAA Network. As a result, the SFY 2019 allocation should be higher if grant funding
remains the same. Following deliberations with the Network that led to an agreement on data sources
and funding factors to be used beginning in SFY 2018 and going forward, the funding formula for
LIHEAP has been revised for SFY 2018 as follows:
Funds will be distributed based on the following factors: number of individuals at or below 125 percent
of the Federal Poverty Level and urban or rural status. The sources used for the poverty and rural
factors were the 2015 Five year American Community Survey and the 2010 United States Census,
respectively.
Poverty Factor Rural Factor Tribal Adjustment
95% 5% Yes
For SFY 2018, agencies were to be held harmless for 50 percent of reductions if said reduction is eight
percent or greater. However, due to a decrease in allocations, all eligible entities lost funding and the
hold-harmless formula was not triggered.
Tucson Urban League will not be receiving LIHEAP funding for SFY 2018. The funds will be allocated
to Pima County Community Action Agency for SFY 2018 and future years.
The following revised initial contract allocations are being made to designated LIHEAP providers.
Agency Allocation
City of Glendale Community Action Program $649,861
City of Phoenix Human Services Department $4,500,051
Maricopa County Human Services Department $2,675,630
Mesa Community Action Network $1,014,129
Pima County Community Action Agency $2,404,900
Coconino County Community Services Department $313,479
Northern Arizona Council of Governments $863,147
Western Arizona Council of Governments $1,371,851
Community Action Human Resources Agency $931,460
Gila County Division of Health and Community Services $128,071
Southeastern Arizona Community Action Program $636,972
Subtotal $15,489,551
Arizona Department of Housing $2,965,186
Tohono O’odham Nation $62,572
Subtotal $18,517,309
Arizona Community Action Association $25,000
Total $18,542,309

Division of Aging and Adult Services
ALERT
SFY-18-B
Low Income Home Energy Assistance Program (LIHEAP)
for SFY 2018
These funds must be fully expended by June 30, 2018.
The LIHEAP funds include provider administration, vouchers, and Assurance 16. Please note that
Assurance 16 funds are to be used for services that encourage and enable households to reduce their
home energy needs and, thereby, the need for energy assistance, including needs assessments,
counseling, and assistance with energy education.
There is a 15 percent set-aside for low-income residential weatherization to be coordinated through the
Arizona Department of Housing. One percent ($29,652) of the total weatherization allocation is
approved for training purposes. This amount is unchanged.
An allocation of $25,000 is made to the Arizona Community Action Association for Leveraging Activities
allowed under the governing legislation. This amount is unchanged.
Should you have any questions or require additional information, please contact your assigned
Contract Specialist.

LIHEAP
Community Action Network Funding Formula SFY 2018 SFY 18-B
Proposed Funding Components
Fund Source - LIHEAP (Funding $18,542,309) 5% 95%
Funds % of Funds
2010 census % of
distributed Allocation distributed
persons @ or % of Total 12 Month Total FY 2018 Hold SFY 2018
District Agency Served based on based on based on % of
below 125% of Allocation Allocation Harmless Allocation
urban or urban/rural persons @ or
poverty
rural status status below 125%
District 1
CITY OF GLENDALE Maricopa/Glendale 0.00% $ 649,861 4.42% 4.20% $ 649,861 $ - $ 649,861
CITY OF PHOENIX Maricopa/Phx 0.00% $ 4,500,051 30.58% 29.05% $ 4,500,051 $ - $ 4,500,051
MARICOPA COUNTY Maricopa/balance $ 27,033 3.49% $ 2,648,597 18.00% 17.27% $ 2,675,630 $ - $ 2,675,630
MesaCAN Maricopa/Mesa 0.00% $ 1,014,129 6.89% 6.55% $ 1,014,129 $ - $ 1,014,129
District 2
PIMA COUNTY Pima $ 15,085 1.95% $ 2,389,815 16.24% 15.53% $ 2,404,900 $ - $ 2,404,900
District 3
COCONINO COUNTY Coconino $ 54,083 6.98% $ 259,396 1.76% 2.02% $ 313,479 $ - $ 313,479
NACOG Totals $ 148,913 $ 714,234 5.57% $ 863,147 $ - $ 863,147
Apache $ 10,154 1.31% $ 48,702 0.33% $ 58,856
Navajo $ 43,073 5.56% $ 206,592 1.40% $ 249,665
Yavapai $ 95,686 12.35% $ 458,940 3.12% $ 554,626
District 4 WACOG Totals $ 236,678 $ 1,135,173 8.86% $ 1,371,851 $ - $ 1,371,851
La Paz $ 6,002 0.77% $ 28,785 0.20% $ 34,787
Mohave $ 108,735 14.04% $ 521,524 3.54% $ 630,259
Yuma $ 121,941 15.74% $ 584,864 3.97% $ 706,805
District 5
CAHRA Pinal $ 160,698 20.75% $ 770,762 5.24% 6.01% $ 931,460 $ - $ 931,460
GILA COUNTY Gila $ 22,095 2.85% $ 105,976 0.72% 0.83% $ 128,071 $ - $ 128,071
District 6
SEACAP Totals $ 109,893 $ 527,079 4.11% $ 636,972 $ - $ 636,972
Cochise $ 60,300 7.79% $ 289,215 1.97% $ 349,515
Graham $ 13,637 1.76% $ 65,407 0.44% $ 79,044
Greenlee $ 4,101 0.53% $ 19,671 0.13% $ 23,772
Santa Cruz $ 31,855 4.11% $ 152,786 1.04% $ 184,641
Totals $ 774,478 100% $ 14,715,073 100% 100% $ 15,489,551 $ - $ 15,489,551
ACAA - Leveraging $ 25,000 $ 25,000
AZ Dept. of Housing (ADOH) $ 2,965,186 $ 2,965,186
Tohono O'odham $ 62,572 $ 62,572
Total (Tohono/ACAA/ADOH) $ 3,052,758 $ 3,052,758
Total $ 18,542,309 $ - $ 18,542,309
LIHEAP
5% Rural $ 774,478.00 $ 774,478
95% Poverty $ 14,715,073.00 $ 14,715,073
Tohono O'odham $ 62,572.00 $ 62,572
ACAA - Leveraging $ 25,000.00 $ 25,000
AZ Dept. of Housing $ 2,965,186.00 $ 2,965,186
$ 15,489,551.00 $ 15,489,551
Total $ 18,542,309.00 $ - $ 18,542,309
$ 15,489,551
Diff $ - $ -

Division of Aging and Adult Services
ALERT
SFY-18-E
Temporary Assistance for Needy Families (TANF)
for SFY 2018
The Division of Aging and Adult Services (DAAS) estimates receipt of Temporary Assistance for
Needy Families (TANF) State Fiscal Year (SFY) 2018 appropriation in the amount of $3,724,000.
The final SFY 2018 TANF appropriation has not been received. Consequently, level funding
estimates have been used to determine SFY 2018 contract allocations. When DAAS receives the
final SFY 2018 appropriation for Community and Emergency Services, TANF allocations may be
adjusted accordingly and a new ALERT may be issued.
Funds will be distributed based on the following factors: number of individuals at or below 125
percent of the Federal Poverty Level, low-income families with children under 18, urban or rural
status, and a minimum funding variable. The sources used for the poverty and low income families
with children under 18 data was the 2015 Five Year American Community Survey and the 2010
United States Census for the rural factors, respectively.
Migrant/
Poverty Rural Extreme Tribal Seasonal Minimum Funding
Factor Factor Poverty Adjustment Farmworker Variable
Adjustment
90% 5% 5% Yes 2% $150,000
The following initial contract allocations are being made to designated Community Action Agencies
and the Limited Purpose Agency serving Migrant and Seasonal Farm Workers for SFY 2018.
Agency Allocation
City of Glendale Community Action Program $ 150,000
City of Phoenix Human Services Department $ 985,710
Coconino County Community Services Department $ 150,000
Community Action Human Resources Agency $ 216,673
Gila County Division of Health and Community Services $ 150,000
Maricopa County Human Services Department $ 593,324
Mesa Community Action Network $ 221,232
Northern Arizona Council of Governments $ 186,134
Pima County Community Action Agency $ 540,565
Southeastern Arizona Community Action Program $ 150,000
Western Arizona Council of Governments $ 305,882
Subtotal $ 3,649,520
Portable, Practical Education Preparation $ 74,480
Total $ 3,724,000
These funds must be fully expended by June 30, 2018.
Should you have any questions or require further information, please contact your assigned Contract
Specialist.

TANF
Community Action Network Funding Formula SFY 2018
Proposed Funding Components 2010 Census Alert 18-E
Fund Source - TANF (Funding $3,724,000)
5% 5% 90% $150,000
Funds Low Income Funds distributed Minimu
2010 census Total Allocation
Rural distributed Families w/ based on low Funds distributed Minimum Adjusted for Adjustment Revised 12 m Minimum
persons @ or % of Total Using Rural 12 Month Total
District Agency Served Population based on children income families with based on persons at or Funding $150,000 Minimum for Hold Month Funding Funding
below 125% of Allocation and Poverty Allocation
Internal % urban or rural under age 18 children under age below 125% of poverty Variable Funding Variable Harmless Allocation Variable Variable $$
poverty % Factors
status % 18 %
District 1
CITY OF GLENDALE Maricopa/Glendale 0.0% 4.4% $ 8,869.00 4.9% $ 143,034.00 4% $ 151,903 $ - $ 151,903 $ (1,903) $ 150,000 $ - $ 150,000
CITY OF PHOENIX Maricopa/Phoenix 0.0% 30.2% $ 59,639.00 32.7% $ 990,458.00 28% $ 1,050,097 $ - $ 1,050,097 $ (64,387) $ 985,710 $ - $ 985,710 32.3% $ 2,289.00
MARICOPA COUNTY Maricopa/balance 4.5% $ 8,292.00 18.1% $ 30,137.00 16.5% $ 593,651.00 17% $ 632,080 $ - $ 632,080 $ (38,756) $ 593,324 $ - $ 593,324 19.5% $ 1,378.00
MesaCAN Maricopa/Mesa 0.0% 6.8% $ 12,474.00 6.8% $ 223,209.00 6% $ 235,683 $ - $ 235,683 $ (14,451) $ 221,232 $ - $ 221,232 7.3% $ 514.00
District 2
PIMA COUNTY Pima/balance 3.6% $ 6,554.00 16.5% $ 28,239.00 15.5% $541,081.00 15% $ 575,874 $ - $ 575,874 $ (35,309) $ 540,565 $ - $ 540,565 17.7% $ 1,255.00
District 3
COCONINO COUNTY Coconino 6.6% $ 12,067.00 1.7% $ 2,653.00 1.5% $57,093.00 2% $ 71,813 $ 78,187 $ - $ - $ 150,000 $ - $ 150,000
NACOG Totals $ 33,225.00 $ 7,864.00 $157,203.00 5% $ 198,292 $ - $ 198,292 $ (12,158) $ 186,134 $ - $ 186,134 6.1% $ 432.00
Apache 1.2% $ 2,266.00 0.3% $ 490.00 0.3% $10,720.00 $ 13,476 7% $ (826) $ 12,650
Navajo 5.3% $ 9,610.00 1.4% $ 2,540.00 1.4% $45,471.00 $ 57,621 29% $ (3,533) $ 54,088
Yavapai 11.7% $ 21,349.00 3.1% $ 4,834.00 2.6% $101,012.00 $ 127,195 64% $ (7,799) $ 119,396
District 4 WACOG Totals $ 54,317.00 $ 14,541.00 $257,004.00 9% $ 325,862 $ - $ 325,862 $ (19,980) $ 305,882 $ - $ 305,882 10.0% $ 710.00
La Paz 1.4% $ 2,595.00 0.4% $ 527.00 0.3% $12,280.00 $ 15,402 5% $ (944) $ 14,458
Mohave 13.3% $ 24,260.00 3.5% $ 5,424.00 3.0% $114,787.00 $ 144,471 44% $ (8,858) $ 135,613
Yuma 15.0% $ 27,462.00 4.0% $ 8,590.00 4.7% $129,937.00 $ 165,989 51% $ (10,178) $ 155,811
District 5
CAHRA Pinal 21.1% $ 38,572.00 5.6% $ 9,754.00 5.3% $182,500.00 6% $ 230,826 $ - $ 230,826 $ (14,153) $ 216,673 $ - $ 216,673 7.1% $ 503.00
GILA COUNTY Gila 2.7% $ 4,930.00 0.7% $ 1,221.00 0.7% $23,325.00 1% $ 29,476 $ 120,524 $ - $ - $ 150,000 $ - $ 150,000
District 6 SEACAP Totals $ 24,519.00 $ 7,085.00 $116,010.00 4% $ 147,614 $ 2,386 $ - $ - $ 150,000 $ - $ 150,000
Cochise 7.4% $ 13,454.00 1.9% $ 3,891.00 2.1% $63,656.00 $ 81,001 54.87% $ 82,310 $ 163,311
Graham 1.7% $ 3,043.00 0.4% $ 877.00 0.5% $14,396.00 $ 18,316 12.41% $ 18,612 $ 36,928
Greenlee 0.5% $ 915.00 0.1% $ 232.00 0.1% $4,330.00 $ 5,477 3.71% $ 5,566 $ 11,043
Santa Cruz 3.9% $ 7,107.00 1.0% $ 2,085.00 1.1% $33,628.00 $ 42,820 29.01% $ 43,512 $ 45,597
Totals 100% $ 182,476.00 100% $ 182,476.00 100% $3,284,568.00 98% $ 3,649,520 $ 201,097 $ 3,400,618 $ (201,097) $ 3,649,520 $ - $ 3,649,520 100% $ 7,081.00
$ 3,248,715
PPEP 2% $ 74,480 $ 74,480.00 $ - $ 74,480.00
Totals 100% $ 3,724,000 $ 3,724,000 $ - $ 3,724,000
GRAND TOTALS
TANF
Funds less PPEP $ 3,649,520.00
$ 3,102,092.00
PPEP $ 74,480.00
5% Rural $ 182,476.00
5% Families $ 182,476.00
$ 3,649,520.00 90% Poverty $ 3,284,568.00
Total Funding $ 3,724,000.00
(Over)/Under $ -

Division of Aging and Adult Services
ALERT
SFY-18-G
Social Services Block Grant (SSBG)
Locally Planned for SFY 2018
The State of Arizona’s allotment of the national Social Services Block Grant (SSBG) appropriation is
determined by the United States Department of Health and Human Services, based on the portion of
the national population that resides in Arizona.
The locally planned SSBG allocations of $1,194,236 listed below reflect current St at e Fisc al
Ye a r ( SFY) 2017 funding levels. After SFY 2017 locally planned SSBG funding levels are
received, adjustments will be made. SSBG allocations are made to Community Services Block Grant
(CSBG) eligible entities and allocated based on the proportional share of low-income persons
residing in a service area.
Agency Allocation
City of Glendale Community Action Program $ 77,890
City of Phoenix Human Services Department $ 574,714
Coconino County Community Services Department $ 18,305
Community Action Human Resources Agency $ 16,096
Gila County Division of Health and Community Services $ 8,048
Maricopa County Human Services Department $ 316,323
Mesa Community Action Network $ 116,279
Northern Arizona Council of Governments $ 66,581
Pima County Community Action Agency $ -
Southeastern Arizona Community Action Program $ -
Western Arizona Council of Governments $ -
Total $ 1,194,236
These funds must be fully expended by June 30, 2018.
Should you have any questions or require additional information, please contact your assigned
Contract Specialist.

SSBG
Community Action Network Funding SFY 2018 Alert 18-G
Proposed Funding Components
Fund Source - SSBG (Funding $1,194,236)
Locally Planned
District Agency Served % of State Allocation
District I City of Glendale Maricopa/Glendale 6.52% $ 77,890
City of Phoenix Maricopa/Phx 48.11% $ 574,714
Maricopa County Maricopa/balance 26.49% $ 316,323
MesaCAN Maricopa/Mesa 9.74% $ 116,279
District II Pima County Pima/balance 0.00% $ -
District III Coconino County Coconino 1.53% $ 18,305
NACOG Multi-county 5.58% $ 66,581
District IV WACOG Multi-county 0.00% $ -
District V CAHRA Pinal 1.35% $ 16,096
Gila County Gila 0.67% $ 8,048
District VI SEACAP Multi-county 0.00% $ -
TOTAL 100% $ 1,194,236

DIVISION OF AGING & ADULT SERVICES
Alert 18-G
SSBG FUNDS FOR SFY 2018
CONTRACTING LEVELS
SFY-2018 SFY-2018
LOCAL SFY-2018 LOCAL
TARGET PLAN TOTAL SSBG
COUNTY/PROVIDER SERVICE GROUP SSBG FUNDS (+)/(-)
DISTRICT I
MARICOPA
City of Phoenix CMT AFC $ 574,714.00 $ 574,714.00 $ -
City of Glendale CMT AFC $ 77,890.00 $ 77,890.00 $ -
Maricopa County CMT AFC $ 316,323.00 $ 316,323.00 $ -
MesaCAN CMT AFC $ 116,279.00 $ 116,279.00 $ -
DISTRICT 1 TOTAL $ 1,085,206.00 $ 1,085,206.00 $ -

DIVISION OF AGING & ADULT SERVICES
Alert 18-G
SSBG FUNDS FOR SFY 2018
CONTRACTING LEVELS
SFY-2018 SFY-2018
LOCAL SFY-2018 LOCAL
TARGET PLAN TOTAL SSBG
COUNTY/PROVIDER SERVICE GROUP SSBG FUNDS (+)/(-)
DISTRICT III
APACHE
COUNTY TOTAL $ - $ - $ -
COCONINO
Coconino County CMT AFC - Crisis Intervention $ 6,745.00 $ 6,745.00 $ -
Coconino County TNS ELD/PWD Low Income $ 11,560.00 $ 11,560.00 $ -
COUNTY TOTAL $ 18,305.00 $ 18,305.00 $ -
NAVAJO
NACOG CMT AFC - Crisis Intervention $ 15,460.00 $ 15,460.00 $ -
NACOG TNS AFC $ 4,548.00 $ 4,548.00 $ -
COUNTY TOTAL $ 20,008.00 $ 20,008.00 $ -
YAVAPAI
NACOG CMT AFC - Crisis Intervention $ 11,644.00 $ 11,644.00
NACOG CMT AFC - Crisis Intervention $ 5,821.00 $ 5,821.00
NACOG TNS AFC $ 29,108.00 $ 29,108.00 $ -
COUNTY TOTAL $ 46,573.00 $ 46,573.00 $ -
DISTRICT 3 TOTAL $ 84,886.00 $ 84,886.00 $ -

DIVISION OF AGING & ADULT SERVICES
Alert 18-G
SSBG FUNDS FOR SFY 2018
CONTRACTING LEVELS
SFY-2018 SFY-2018
LOCAL SFY-2018 LOCAL
TARGET PLAN TOTAL SSBG
COUNTY/PROVIDER SERVICE GROUP SSBG FUNDS (+)/(-)
DISTRICT V
GILA
Gila County CMT AFC $ 8,048.00 $ 8,048.00 $ -
COUNTY TOTAL $ 8,048.00 $ 8,048.00 $ -
PINAL
CAHRA CMT AFC $ 16,096.00 $ 16,096.00 $ -
COUNTY TOTAL $ 16,096.00 $ 16,096.00 $ -
DISTRICT 5 TOTAL $ 24,144.00 $ 24,144.00 $ -

DIVISION OF AGING & ADULT SERVICES
Alert 18-G
SSBG FUNDS FOR SFY 2018
CONTRACTING LEVELS
INITIAL REVISED
SFY-2018 SFY-2018
LOCAL LOCAL SFY-2018
PLAN PLAN TOTAL
DISTRICT SSBG SSBG SSBG
I $ 1,085,206.00 $ - $ 1,085,206.00
II $ - $ - $ -
III $ 84,886.00 $ - $ 84,886.00
IV $ - $ - $ -
V $ 24,144.00 $ - $ 24,144.00
VI $ - $ - $ -
TOTAL $ 1,194,236.00 $ - $ 1,194,236.00

Division of Aging and Adult Services
ALERT
SFY-18-I
Neighbors Helping Neighbors (NHN)
for SFY 2018
The Division of Aging and Adult Services (DAAS) estimates receiving $35,000 in Neighbors
Helping Neighbors (NHN) funds for State Fiscal Year (SFY) 2018 to provide utility assistance
services. There has been a decrease in the number of taxpayers currently selecting to contribute
to NHN through the tax check-off box on Arizona State Income Tax forms. If deposits lessen,
allocations may be adjusted accordingly and a new ALERT may be issued. NHN funds are utilized
in the same manner as Low Income Home Energy Assistance Program (LIHEAP) Base Funds.
Funds will be distributed based on the following factors: number of individuals at or below 125
percent of the Federal Poverty Level and urban or rural status. The sources used for the poverty and
rural factors were the 2015 Five year American Community Survey and the 2010 United States.
Census, respectively.
Tucson Urban League will not be receiving Neighbors Helping Neighbors funding for SFY 2018. The
funds will be allocated to Pima County Community Action Agency for SFY 2018 and future years.
Poverty Factor Rural Factor Tribal Adjustment
95% 5% Yes
The following initial contract allocations are being made to the respective contractors:
Agency Allocation
City of Glendale Community Action Program $ 1,468
City of Phoenix Human Services Department $ 10,168
Coconino County Community Services Department $ 708
Community Action Human Resources Agency $ 2,105
Gila County Division of Health and Community Services $ 289
Maricopa County Human Services Department $ 6,046
Mesa Community Action Network $ 2,292
Northern Arizona Council of Governments $ 1,950
Pima County Community Action Agency $ 5,434
Southeastern Arizona Community Action Program $ 1,439
Western Arizona Council of Governments $ 3,101
Total $ 35,000
These funds must be fully expended by June 30, 2018.
Should you have any questions or require additional information, please contact your assigned
Contract Specialist.

NHN
Community Action Network Funding Formula SFY 2018 SFY 18-I
Proposed Funding Components
Fund Source - NHN (Funding $35,000) 5% 95%
Funds
Funds distributed 2010 census % of
distributed % of Allocation
based on % of persons @ or % of Total 12 Month Total SFY 2018
District Agency Served based on based on
persons @ or below below 125% of Allocation Allocation Allocation
urban or rural urban/rural status
125% of poverty poverty
status
District 1
CITY OF GLENDALE Maricopa/Glendale $ - 0.00% $ 1,468 4.42% 4.20% $ 1,468 $ 1,468
CITY OF PHOENIX Maricopa/Phx $ - 0.00% $ 10,168 30.58% 29.05% $ 10,168 $ 10,168
MARICOPA COUNTY Maricopa/balance $ 61 3.49% $ 5,985 18.00% 17.27% $ 6,046 $ 6,046
MesaCAN Maricopa/Mesa $ - 0.00% $ 2,292 6.89% 6.55% $ 2,292 $ 2,292
District 2
PIMA COUNTY Pima/balance $ 34 1.95% $ 5,400 16.24% 15.53% $ 5,434 $ 5,434
District 3
COCONINO COUNTY Coconino $ 122 6.98% $ 586 1.76% 2.02% $ 708 $ 708
NACOG Totals $ 336 $ 1,614 5.57% $ 1,950 $ 1,950
Apache $ 23 1.31% $ 110 0.33% $ 133
Navajo $ 97 5.56% $ 467 1.40% $ 564
Yavapai $ 216 12.35% $ 1,037 3.12% $ 1,253
District 4 WACOG Totals $ 535 $ 2,566 8.86% $ 3,101 $ 3,101
La Paz $ 14 0.77% $ 65 0.20% $ 79
Mohave $ 246 14.04% $ 1,178 3.54% $ 1,424
Yuma $ 276 15.74% $ 1,322 3.97% $ 1,597
District 5
CAHRA Pinal $ 363 20.75% $ 1,742 5.24% 6.01% $ 2,105 $ 2,105
GILA COUNTY Gila $ 50 2.85% $ 239 0.72% 0.83% $ 289 $ 289
District 6
SEACAP Totals $ 248 $ 1,191 4.11% $ 1,439 $ 1,439
Cochise $ 136 7.79% $ 654 1.97% $ 790
Graham $ 31 1.76% $ 148 0.44% $ 179
Greenlee $ 9 0.53% $ 44 0.13% $ 54
Santa Cruz $ 72 4.11% $ 345 1.04% $ 417
Totals $ 1,751 100% $ 33,250 100% 100% $ 35,000 $ 35,000
NHN
5% Rural $ 1,750.00 $ 1,750
95% Poverty $ 33,250.00 $ 33,250
Total $ 35,000.00 $ 35,000

COMMUNITY ACTION NETWORK FORMULA
SFY 2018 ALLOCATIONS
CSBG CSBG LIHEAP SFY 2018
CSBG Discretionary Carryover LIHEAP Re-distributed TANF SSBG NHN ALLOCATION
ACAA $ - $ 163,284 $ - $ 25,000 $ - $ - $ - $ - $ 188,284
CAHRA $ 355,893 $ - $ - $ 931,460 $ - $ 216,673 $ 16,096 $ 2,105 $ 1,522,227
City of Glendale $ 232,350 $ - $ - $ 649,861 $ - $ 150,000 $ 77,890 $ 1,468 $ 1,111,569
City of Phoenix $ 1,609,418 $ 23,611 $ - $ 4,500,051 $ - $ 985,710 $ 574,714 $ 10,168 $ 7,703,672
Coconino County $ 150,000 $ 16,569 $ - $ 313,479 $ - $ 150,000 $ 18,305 $ 708 $ 649,061
Arizona Dept of Housing $ - $ - $ - $ 2,965,186 $ - $ - $ - $ - $ 2,965,186
Gila County $ 150,000 $ - $ - $ 128,071 $ - $ 150,000 $ 8,048 $ 289 $ 436,408
Maricopa County $ 977,885 $ - $ - $ 2,675,630 $ - $ 593,324 $ 316,323 $ 6,046 $ 4,569,208
MesaCAN $ 361,063 $ 28,995 $ - $ 1,014,129 $ - $ 221,232 $ 116,279 $ 2,292 $ 1,743,990
NACOG $ 305,074 $ - $ - $ 863,147 $ - $ 186,134 $ 66,581 $ 1,950 $ 1,422,886
Pima County $ 887,354 $ 28,101 $ - $ 2,404,900 $ - $ 540,565 $ - $ 5,434 $ 3,866,354
PPEP $ 117,366 $ - $ - $ - $ - $ 74,480 $ - $ - $ 191,846
SEACAP $ 225,162 $ - $ - $ 636,972 $ - $ 150,000 $ - $ 1,439 $ 1,013,573
Tohono O'odham $ - $ - $ - $ 62,572 $ - $ - $ - $ - $ 62,572
WACOG $ 496,725 $ - $ - $ 1,371,851 $ - $ 305,882 $ - $ 3,101 $ 2,177,559
Totals $ 5,868,290 $ 260,560 $ - $ 18,542,309 $ - $ 3,724,000 $ 1,194,236 $ 35,000 $ 29,624,395

ACAA
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ - $ - $ -
CSBG Discretionary $ 163,284 $ - $ 163,284
CSBG Carryover $ - $ - $ -
LIHEAP $ 25,000 $ - $ 25,000
LIHEAP Re-distributed $ - $ - $ -
TANF $ - $ - $ -
SSBG $ - $ - $ -
NHN $ - $ - $ -
TOTAL $ 188,284 $ - $ 188,284
Bolded numbers represent changes in funding.

CAHRA
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 355,893 $ - $ 355,893
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ 931,460 $ - $ 931,460
LIHEAP Re-distributed $ - $ - $ -
TANF $ 216,673 $ - $ 216,673
SSBG $ 16,096 $ - $ 16,096
NHN $ 2,105 $ - $ 2,105
TOTAL $ 1,522,227 $ - $ 1,522,227
Bolded numbers represent changes in funding.

CITY OF GLENDALE
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 232,350 $ - $ 232,350
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ 649,861 $ - $ 649,861
LIHEAP Re-distributed $ - $ - $ -
TANF $ 150,000 $ - $ 150,000
SSBG $ 77,890 $ - $ 77,890
NHN $ 1,468 $ - $ 1,468
TOTAL $ 1,111,569 $ - $ 1,111,569
Bolded numbers represent changes in funding.

CITY OF PHOENIX
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 1,609,418 $ - $ 1,609,418
CSBG Discretionary $ 23,611 $ - $ 23,611
CSBG Carryover $ - $ - $ -
LIHEAP $ 4,500,051 $ - $ 4,500,051
LIHEAP Re-distributed $ - $ - $ -
TANF $ 985,710 $ - $ 985,710
SSBG $ 574,714 $ - $ 574,714
NHN $ 10,168 $ - $ 10,168
TOTAL $ 7,703,672 $ - $ 7,703,672
Bolded numbers represent changes in funding.

COCONINO COUNTY
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 150,000 $ - $ 150,000
CSBG Discretionary $ 16,569 $ - $ 16,569
CSBG Carryover $ - $ - $ -
LIHEAP $ 313,479 $ - $ 313,479
LIHEAP Re-distributed $ - $ - $ -
TANF $ 150,000 $ - $ 150,000
SSBG $ 18,305 $ - $ 18,305
NHN $ 708 $ - $ 708
TOTAL $ 649,061 $ - $ 649,061
Bolded numbers represent changes in funding.

GILA COUNTY
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 150,000 $ - $ 150,000
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ 128,071 $ - $ 128,071
LIHEAP Re-distributed $ - $ - $ -
TANF $ 150,000 $ - $ 150,000
SSBG $ 8,048 $ - $ 8,048
NHN $ 289 $ - $ 289
TOTAL $ 436,408 $ - $ 436,408
Bolded numbers represent changes in funding.

ARIZONA DEPARTMENT OF HOUSING
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ - $ - $ -
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ 2,965,186 $ - $ 2,965,186
LIHEAP Re-distributed $ - $ - $ -
TANF $ - $ - $ -
SSBG $ - $ - $ -
NHN $ - $ - $ -
TOTAL $ 2,965,186 $ - $ 2,965,186
Bolded numbers represent changes in funding.

MARICOPA COUNTY
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 977,885 $ - $ 977,885
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ 2,675,630 $ - $ 2,675,630
LIHEAP Re-distributed $ - $ - $ -
TANF $ 593,324 $ - $ 593,324
SSBG $ 316,323 $ - $ 316,323
NHN $ 6,046 $ - $ 6,046
TOTAL $ 4,569,208 $ - $ 4,569,208
Bolded numbers represent changes in funding.

MESA CAN
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 361,063 $ - $ 361,063
CSBG Discretionary $ 28,995 $ - $ 28,995
CSBG Carryover $ - $ - $ -
LIHEAP $ 1,014,129 $ - $ 1,014,129
LIHEAP Re-distributed $ - $ - $ -
TANF $ 221,232 $ - $ 221,232
SSBG $ 116,279 $ - $ 116,279
NHN $ 2,292 $ - $ 2,292
TOTAL $ 1,743,990 $ - $ 1,743,990
Bolded numbers represent changes in funding.

NACOG
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 305,074 $ - $ 305,074
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ 863,147 $ - $ 863,147
LIHEAP Re-distributed $ - $ - $ -
TANF $ 186,134 $ - $ 186,134
SSBG $ 66,581 $ - $ 66,581
NHN $ 1,950 $ - $ 1,950
TOTAL $ 1,422,886 $ - $ 1,422,886
Bolded numbers represent changes in funding.

PIMA COUNTY
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 887,354 $ - $ 887,354
CSBG Discretionary $ 28,101 $ - $ 28,101
CSBG Carryover $ - $ - $ -
LIHEAP $ 2,404,900 $ - $ 2,404,900
LIHEAP Re-distributed $ - $ - $ -
TANF $ 540,565 $ - $ 540,565
SSBG $ - $ - $ -
NHN $ 5,434 $ - $ 5,434
TOTAL $ 3,866,354 $ - $ 3,866,354
Bolded numbers represent changes in funding.

PPEP
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 117,366 $ - $ 117,366
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ - $ - $ -
LIHEAP Re-distributed $ - $ - $ -
TANF $ 74,480 $ - $ 74,480
SSBG $ - $ - $ -
NHN $ - $ - $ -
TOTAL $ 191,846 $ - $ 191,846
Bolded numbers represent changes in funding.

SEACAP
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 225,162 $ - $ 225,162
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ 636,972 $ - $ 636,972
LIHEAP Re-distributed $ - $ - $ -
TANF $ 150,000 $ - $ 150,000
SSBG $ - $ - $ -
NHN $ 1,439 $ - $ 1,439
TOTAL $ 1,013,573 $ - $ 1,013,573
Bolded numbers represent changes in funding.

TOHONO O'ODHAM
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ - $ - $ -
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ 62,572 $ - $ 62,572
LIHEAP Re-distributed $ - $ - $ -
TANF $ - $ - $ -
SSBG $ - $ - $ -
NHN $ - $ - $ -
TOTAL $ 62,572 $ - $ 62,572
Bolded numbers represent changes in funding.

WACOG
Fund Source SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG $ 496,725 $ - $ 496,725
CSBG Discretionary $ - $ - $ -
CSBG Carryover $ - $ - $ -
LIHEAP $ 1,371,851 $ - $ 1,371,851
LIHEAP Re-distributed $ - $ - $ -
TANF $ 305,882 $ - $ 305,882
SSBG $ - $ - $ -
NHN $ 3,101 $ - $ 3,101
TOTAL $ 2,177,559 $ - $ 2,177,559
Bolded numbers represent changes in funding.

STATE TOTALS
Fund Source ALERT DATE ISSUED SFY SFY SFY
2018 2018 2018
Initial Allocation Revised
Allocation Increase/(Decrease) Allocation
CSBG ALERT SFY 18-A 3/17/2017 $ 5,868,290 $ - $ 5,868,290
CSBG Discretionary ALERT SFY 18-A1 3/17/2017 $ 260,560 $ - $ 260,560
CSBG Carryover $ - $ - $ -
LIHEAP ALERT SFY 18-B 3/17/2017 $ 18,542,309 $ - $ 18,542,309
LIHEAP Re-distributed $ - $ - $ -
TANF ALERT SFY 18-E 3/17/2017 $ 3,724,000 $ - $ 3,724,000
SSBG ALERT SFY 18-G 3/17/2017 $ 1,194,236 $ - $ 1,194,236
NHN ALERT SFY 18-I 3/17/2017 $ 35,000 $ - $ 35,000
TOTAL $ 29,624,395 $ - $ 29,624,395
Bolded numbers represent changes in funding.

Division of Aging and Adult Services
ALERT
SFY-18-K
Technical Assistance
for SFY 2018
Technical Assistance ALERTS are generated periodically to update contractual and/or
programmatic requirements and/or clarifications. Please ensure that appropriate Community
Action Agency (CAA) staff are aware of this technical assistance.
Community Action Program Services (CAPS) – Income Eligibility Thresholds for SFY 2018
The SFY 2018 Income Threshold Chart for CAPS becomes effective on July 1, 2017 and will
remain in effect until June 30, 2018. Both the Federal Poverty Guideline (FPG) and the State
Median Income (SMI) have risen slightly for 2017. The income threshold for Low Income Home
Energy Assistance (LIHEAP) eligibility is set at 60 percent of the current SMI, as determined by the
2015 American Community Survey (ACS), Five-Year Estimates, or 150 percent of the current
Federal Poverty Guideline (FPG), whichever is greater. Similar to SFY 2017, in SFY 2018, the 150
percent FPG threshold will still be greater than 60 percent of the SMI for households sized seven
and larger. The income thresholds on the simplified LIHEAP income chart are derived from the
comprehensive CAPS chart (Attachment #1) for all other Community Action Program Services. An
abbreviated chart for use with LIHEAP only is also included in this ALERT (Attachment #2). The
current FPGs are used to determine income eligibility according to the rules and income limits for
each specific program.
These charts will replace the SFY 2017 Income Threshold charts in the LIHEAP and Short-Term
Crisis Services (STCS) Policy and Procedure Manuals beginning July 1, 2017.
If you have any questions or require additional information, please contact Diana Gravett,
Community Action Program Specialist, at dgravett@azdes.gov or (602) 542-6594.

SFY-18-K Attachment 1
Department of Economic Security (DES)
Division of Aging and Adult Services (DAAS)
SFY 2018 Simplified LIHEAP Income Chart
Effective July 1, 2017 to June 30, 2018
60 percent of State Median Income (SMI) is used for households sized 6 and
under
150 percent of Federal Poverty Guideline (FPG) is used for households sized 7
and over
Household Size 30 Day Gross Income Limit
(Dollar Amount)
1 SM I60 percent $1,786
2 2,336
3 2,885
4 3,435
5 3,985
6 4,534
7 FPG 150 percent 4,643
8 5,165
9 5,688
10 6,210
11 6,733
12 7,255
For each additional household member, add $523
3/18/16

SFY-18-K Attachment #2
Arizona Department of Economic Security - Division of Aging and Adult Services (DAAS)
Community Action Programs and Services
Income Thresholds for Community Action Program Services - Effective July 1, 2017 - June 30, 2018
Federal Poverty Guidelines (FPG) - Income thresholds for the last 30 days by percent of FPG
For >12
Number of Household Members>> 1 2 3 4 5 6 7 8 9 10 11 12
Add
0%-75% of Poverty = At or under 75% of the FPG, FYI.. $754 $1,015 $1,015 $1,538 $1,799 $2,060 $2,321 $2,583 $2,844 $3,105 $3,366 $3,628 $261
76%-100% of Poverty = Above 75% and at or below 100%
of FPG. FYI - for reporting and programs with an income $1,005 $1,353 $1,353 $2,050 $2,398 $2,747 $3,095 $3,443 $3,792 $4,140 $4,488 $4,837 $348
limit of 100% of poverty.
101%-125% of Poverty = Above 100% and at or below
125% of FPG. Threshold for: NHN STCS, CSBG clients
aged 59 and under without disabilites. For CSBG/STCS $1,256 $1,692 $1,692 $2,563 $2,998 $3,433 $3,869 $4,304 $4,740 $5,175 $5,610 $6,046 $435
clients 60+ or persons with disabilities see: 126%-150%
of Poverty below.
126%-150% of Poverty = Above 125% and at or below
150% of FPG. Threshold for: STCS, NHN and CSBG
$1,508 $2,030 $2,030 $3,075 $3,598 $4,120 $4,643 $5,165 $5,688 $6,210 $6,733 $7,255 $523
clients aged 60+, persons with disabilities. For LIHEAP
clients see next section, LIHEAP ONLY.
LIHEAP ONLY - Income Thresholds by Household Size
For >12
Number of Household Members>> 1 2 3 4 5 6 7 8 9 10 11 12
Add
The household income limit for the last 30 days for $1,786 $2,336 $2,885 $3,435 $3,985 $4,534 $4,643 $5,165 $5,688 $6,210 $6,733 $7,255 $523
LIHEAP is 60% of SMI for households sized 6 and under.
For households sized 7 and over, the income limit is Income limits for LIHEAP households sized 6 and under using 60% of Income limits for LIHEAP households sized 7 and over (using Federal
150% of FPG - FPL UPDATED FOR SFY 2018 State Median Income Poverty Guidelines)
LIHEAP ONLY - Energy Points for Income by Household Size
For >12
Number of Household Members>> 1 2 3 4 5 6 7 8 9 10 11 12
Add
To determine energy points based upon poverty level
At or below 25% of 60% of SMI or 150% of $447 $584 $721 $859 $996 $1,134 $1,161 $1,291 $1,422 $1,553 $1,683 $1,814 $131
A) 5 points FPG for households sized 7 or more >>
Above 25% and up to 50% of 60% of SMI >>
$893 $1,168 $1,443 $1,718 $1,992 $2,267 $2,321 $2,583 $2,844 $3,105 $3,366 $3,628 $261
B) 4 points or above 150% for households sized 7 or
Above 50% and up to 75% of 60% of the
C) 3 points SMI >>or above 150% for households sized $1,340 $1,752 $2,164 $2,576 $2,988 $3,401 $3,482 $3,874 $4,266 $4,658 $5,049 $5,441 $392
Above 75% of 60% of SMI or above 150% of
$1,786 $2,336 $2,885 $3,435 $3,985 $4,534 $4,643 $5,165 $5,688 $6,210 $6,733 $7,255 $523
D) 2 points FPG for households sized 7 or more. >>

Division of Aging and Adult Services
ALERT
SFY-18-K1
Technical Assistance
for SFY 2018
Technical Assistance ALERTS are generated periodically to update contractual and/or
programmatic requirements and/or clarifications. Please ensure that appropriate Community
Action Agency (CAA) staff are aware of this technical assistance.
Division of Aging and Adult Services, Community Action Program Services (DAAS/CAPS) –
Annual Report/ Results Oriented Management and Accountability (ROMA), Template and
crosswalk documents. Attached are the CSBG Annual Report Template, Attachment #1 and
#1B Module 4 ROMA Catalogue Template, the DAAS/CAPS prepared crosswalk, Attachment #2,
and the crosswalk documents provided by the National Association of State Community Services
Providers (NASCSP), Attachments #3 and #4. During the remainder of State Fiscal Year (SFY),
2017, DAAS/CAPS will work with the Network to determine common indicators for outcome
reporting, and will assist agencies in determining unique indicators on the NPI portions of the
report.
The ROMA catalogue is to be submitted to DAAS/CAPS by June 30, 2017. Information regarding
what is needed for each module is provided below.
Annual Report: For Module 2, agencies are only to report on the capacity and resource elements
that are relevant to their respective activities.
Module 3, Sections A and B, Community Level: agencies will be requested to report on at least
one community level initiative in their Annual Report. Agencies will not be requested to set targets
for the community level initiative in Module 3 Section B in SFY 2018, as part of their ROMA
catalogue.
DAAS/CAPS will assist individual agencies with completing this section. In preparation for
reporting on a community-level initiative, DAAS/CAPS suggests comparing narrative elements of
Module 3 of the new CSBG Annual Report to Section D of the current CSBG IS Report, as this is
the comparable section. When this Module 3, Section A is completed for a particular initiative, the
only ROMA reporting tables that need a response in Section B, are those that match the domains
selected in Section A, Item 5. Example: if “Employment” is selected in Item 5, only the table
labeled “Employment Indicators” in Section B, will need to be completed for that initiative. In
targeted NPI of Module 3, agencies will not complete the “Rates of Change” tables for SFY 2018,
as SFY 2018 is the baseline year.
Module 4, Section A, Individual and Family National Performance Indicators (NPIs): agencies
should use the targeted tables in this section to create their ROMA catalogue for SFY2018.
Section A also included a separate attachment in this ALERT (#1B)
Section B, Individual and Family Services; these items reflect service counts. Agencies will only
report services counts on the services they provide. Section C., Individual and Family
Characteristics (Demographics), agencies will not be required to report new data elements for SFY
2018, but will be requested to provide responses for any new elements for which they are able to
report.
Should you have any questions or require additional information, please contact Diana Gravett,
Community Action Program Specialist, at dgravett@azdes.gov or (602) 542-6594.

SFY-18-K1 Attachment #1
Module 2
CSBG Eligible Entity Expenditures,
Capacity, and Resources
Page 24 of 66

SFY-18-K1 Attachment #1
Instructional Notes
Module 2 - CSBG Eligible Entity Expenditures, Capacity, and
Resources
Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity - Data Entry Form
Section A: CSBG Expenditures by CSBG Eligible Entity Data Entry Form meets the Congressional requirement
for an explanation of the total amount of CSBG funding expended during the reporting period (identified below)
based on categories referenced in the CSBG Act.
CSBG funding expended during the reporting period should be identified in the domain that best reflects
the services delivered and strategies implemented, as well as the administrative costs associated with the
domains. Further instructions will be provided, but please keep the following in mind, per domain:
Services Supporting Multiple Domains: Expenditures reported under Services Supporting Multiple Domains
are those that span or support outcomes achieved across multiple domains for families and individuals,
such as case management, transportation, and childcare.
Linkages: Many of the activities that were associated with Linkages are now captured in Domain 9: Agency
Capacity Building. This narrows the definition of Linkages, but continues to include community initiatives
and information and referral calls.
Agency Capacity Building: Expenditures for Agency Capacity Building are detailed in Table B on this form.
Reporting on Administration: Administrative costs for CSBG reporting are defined by the Office of
Community Services as “equivalent to typical indirect costs or overhead." As distinguished from program
administration or management expenditures that qualify as direct costs, administrative costs refer to
central executive functions that do not directly support a specific project or service.
Module 2, Section B: CSBG Eligible Entity Capacity Building - Data Entry Form
Section B: CSBG Eligible Entity Capacity Building Data Entry Form provides detail on agency capacity building
funded by CSBG and other funding sources.
Module 2, Section C: Allocated Resources per CSBG Eligible Entity - Data Entry Form
Section C: Allocated Resources per CSBG Eligible Entity data entry form provides data on resources allocated
to, administered through, and generated by the CSBG Eligible Entity. This report provides valuable information
on how CSBG leverages funds from multiple federal, state, local, and private sources as required in the CSBG
Act.
FRN #2 –CSBG Annual Report
October 2016 Module 2, Instructional Notes Page 25 of 66

SFY-18-K1 Attachment #1
Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity - Data Entry Form
Name of CSBG Eligible Entity Reporting:
A. CSBG Eligible Entity Reporting Period "X"
1. July 1 - June 30
2. October 1 - September 30
3. January 1 - December 31
B. CSBG Expenditures Domains CSBG Funds
1. Employment
2. Education and Cognitive Development
3. Income, Infrastructure, and Asset Building
4. Housing
5. Health and Social/Behavioral Development (includes nutrition)
6. Civic Engagement and Community Involvement
7. Services Supporting Multiple Domains
8. Linkages (e.g. partnerships that support multiple domains)
9. Agency Capacity Building (detailed below in Table C)
10. Other (e.g. emergency management/disaster relief)
Total CSBG Expenditures (auto calculated) $0
Of the CSBG funds reported above, report the total amount used for Administration. For more information on
what qualifies as Administration, refer to IM37.
C. Details on Agency Capacity Building Activities Funded by CSBG:
1. Please identify which activities were funded by CSBG under Agency Capacity in Table B. Please check all that apply.
Community Needs Assessment Data Management & Reporting Other*
Strategic Planning Training & Technical Assistance
*Below please specify Other Activities funded by CSBG under Agency Capacity:
October 2016 FRN #2 – CSBG Annual Report Page 26 of 66
Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity

SFY-18-K1 Attachment #1
Module 2, Section B: CSBG Eligible Entity Capacity Building - Data Entry Form
Name of CSBG Eligible Entity:
A. CSBG Eligible Entity Reporting Period "X"
1. July 1 - June 30
auto-populated from Module
2. October 1 - September 30 2, Section A
3. January 1 - December 31
B. Hours of Agency Capacity Building (e.g. training, planning, assessment): Hours
1. Hours of Board Members in capacity building activities
2. Hours of Agency Staff in capacity building activities
C. Volunteer Hours of Agency Capacity Building (e.g. program support, service delivery, fundraising): Hours
1. Total number of volunteer hours donated to the agency
a. Of the above, the total number of volunteer hours donated by individuals with low-incomes
D. The number of staff who hold certifications that increase agency capacity to achieve family and community
Number
outcomes, as measured by one or more of the following:
1. Number of Nationally Certified ROMA Trainers
2. Number of Nationally Certified ROMA Implementers
3. Number of Certified Community Action Professionals (CCAP)
4. Number of Staff with a child development certification
5. Number of Staff with a family development certification
6. Number of Pathways Reviewers
7. Number of Staff with Home Energy Professional Certifications
a. Number of Energy Auditors
b. Number of Retrofit Installer Technicians
c. Number of Crew Leaders
d. Number of Quality Control Inspectors (QCI)
8. Number of LEED Risk Certified assessors
9. Number of Building Performance Institute (BPI) certified professionals
10. Number of Classroom Assessment Scoring System (CLASS) certified professionals
11. Number of Certified Housing Quality Standards (HQS) Inspectors
12. Number of American Institute of Certified Planners (AICP)
13. Other (Please specify others below):
E. Number of organizations, both public and private, that the CSBG Eligible Entity actively works with to expand Unduplicated Number of
resources and opportunities in order to achieve family and community outcomes: Organizations
1. Non-Profit
2. Faith Based
3. Local Government
4. State Government
5. Federal Government
6. For-Profit Business or Corporation
7. Consortiums/Collaborations
8. School Districts
9. Institutions of Post-Secondary Education/Training
10. Financial/Banking Institutions
11. Health Service Organizations
12. Statewide Associations or Collaborations
FRN #2 – CSBG Annual Report Page 27 of 66
October 2016 Module 2, Section B: CSBG Eligible Entity Capacity Building

SFY-18-K1 Attachment #1
Module 2, Section C: Allocated Resources per CSBG Eligible Entity -
Data Entry Form
Name of CSBG Eligible Entity:
A. CSBG Eligible Entity Reporting Period "X"
1. July 1 - June 30
2. October 1 - September 30 auto-populated from Module 2, Section A
3. January 1 - December 31
B. Amount of FY 20XX CSBG allocated to reporting entity
C. Federal Resources Allocated (Other than CSBG)
1. Weatherization (DOE) (include oil overcharge $$ ) 1.
2. Health and Human Services (HHS)
a. LIHEAP - Fuel Assistance (include oil overcharge $$ ) 2a.
b. LIHEAP - Weatherization (include oil overcharge $$ ) 2b.
c. Head Start 2c.
d. Early Head Start 2d.
e. Older Americans Act 2e.
f. Social Services Block Grant (SSBG) 2f.
g. Medicare/Medicaid 2g.
h. Assets for Independence (AFI) 2h.
i. Temporary Assistance for Needy Families (TANF) 2i.
j. Child Care Development Block Grant (CCDBG) 2j.
k. Community Economic Development (CED) 2k.
l. Other HHS Resources
i. CFDA #: 2l.i
ii. CFDA #: 2l.ii
iii. CFDA #: 2l.iii
iv. CFDA #: 2l.iv
2l. Total Other HHS Resources (autocalculated) 2l. $ -
3. Department of Agriculture (USDA)
a. Special Supplemental Nutrition for Women, Infants, and Children (WIC) 3a.
b. All USDA Non-Food programs (e.g. rural development) 3b.
c. All other USDA Food programs 3c.
4. Department of Housing and Urban Development (HUD)
a. Community Development Block Grant (CDBG) - Federal, State, and Local 4a.
b. Section 8 4b.
c. Section 202 4c.
d. Home Tenant-Based Rental Assistance (HOME TBRA) 4d.
e. HOPE for Homeowners Program (H4H) 4e.
f. Emergency Solutions Grant (ESG) 4f.
g. Continuum of Care (CoC) 4g.
h. All other HUD programs, including homeless programs 4h.
5. Department of Labor (DOL)
a. Workforce Innovation and Opportunity Act (WIOA) *previously WIA 5a.
b. Other DOL Employment and Training programs 5b.
c. All other DOL programs 5c.
6. Corporation for National and Community Service (CNCS) programs 6.
7. Federal Emergency Management Agency (FEMA) 7.
8. Department of Transportation 8.
9. Department of Education 9.
10. Department of Justice 10.
11. Department of Treasury 11.
12. Other Federal Resources
i. CFDA #: 12.i
ii. CFDA #: 12.ii
iii. CFDA #: 12.iii
iv. CFDA #: 12.iv
13. Total Other Federal Resources (autocalculated) 13. $ -
14. Total: Non-CSBG Federal Resources Allocated (autocalculated) 14 $ -
FRN #2 – CSBG Annual Report Page 28 of 66
October 2016 Module 2, Section C: Allocated Resources per CSBG Eligible Entity

SFY-18-K1 Attachment #1
D. State Resources Allocated
1. a. State appropriated funds used for the same purpose as Federal CSBG funds 1a.
b. State Housing and Homeless programs (include housing tax credits ) 1b.
c. State Nutrition programs 1c.
d. State Early Childhood Programs (e.g. Head Start, Day Care ) 1d.
e. State Energy programs 1e.
f. State Health programs 1f.
g. State Youth Development programs 1g.
h. State Employment and Training programs 1h.
i. State Senior programs 1i.
j. State Transportation programs 1j.
k. State Education programs 1k.
l. State Community, Rural and Economic Development programs 1l.
m. State Family Development programs 1m.
n. Other State Resources
i. 1n.i
ii. 1n.ii
iii. 1n.iii
iv. 1n.iv
1n. Total Other State Resources (autocalculated) 1n. $ -
2. Total: State Resources Allocated (autocalculated) 2. $ -
3. If any of these resources were also reported under Item 15 (Federal Resources), please estimate the 3.
amount.
E. Local Resources Allocated
1. a. Amount of unrestricted funds appropriated by local government 1a.
b. Amount of restricted funds appropriated by local government 1b.
c. Value of Contract Services 1c.
d. Value of in-kind goods/services received from local government 1d.
2. Total: Local Resources Allocated (autocalculated) 2. $ -
If any of these resources were also reported under Item 15 or 17 (Federal or State Resources), please
3. estimate the amount. 3.
F. Private Sector Resources Allocated
1. a. Funds from foundations, corporations, United Way, other nonprofits 1a.
b. Other donated funds 1b.
c. Value of other donated items, food, clothing, furniture, etc. 1c.
d. Value of in-kind services received from businesses 1d.
e. Payments by clients for services 1e.
f. Payments by private entities for goods or services for low income 1f.
clients or communities
2. Total: Private Sector Resources Allocated (autocalculated) 2. $ -
3. If any of these resources were also reported under Item 15, 17, or 20 (Federal, State or Local Resources), 3.
please estimate the amount.
G. Total Non-CSBG Resources Allocated: (Federal, State, Local & Private) (autocalculated) G. $ -
H. Total Resources in CSBG Eligible Entity (including CSBG) (autocalculated) H. $ -
Note : * All totals are autocalculated
FRN #2 – CSBG Annual Report Page 29 of 66
October 2016 Module 2, Section C: Allocated Resources per CSBG Eligible Entity

SFY-18-K1 Attachment #1
Module 3
Community Level
Page 30 of 66

Instructional Notes
Module 3 - Community Level
Module 3, Section A: Community Initiative Status Form
CSBG Eligible Entities will complete the Community Initiative Status Form for the CSBG Eligible Entity identified
initiatives intended to achieve community level outcomes. This form provides a central place to report valuable
information about a single community initiative that started, continued, or ended during the current reporting
period. The information reported on the status form will be selected via a dropdown menu or written as a
narrative. In future reporting periods, CSBG Eligible Entities will update the status form based on the initiative's
progress. Please see additional notes below:
Problem Identification: CSBG Eligible Entities will provide information on how the problem was identified in
the Community Needs Assessment. This will include any data collected.
Issue/CSBG Community Domains: Select the domain(s) category(ies) that best describe the issue addressed
by the initiative. A full list is provided in the Status Form.
Ultimate Expected Outcomes: Select the indicator(s) from the Community Level NPIs (full list is found in
Section B) that measures the ultimate expected outcome of the initiative OR enter an "Other Outcome
Indicator".
Partnership Type: Select the partnership type from the choices provided. For example, a multi-partner
initiative includes the CSBG Eligible Entity and one or more partners.
Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
To facilitate the reporting, use, and learning from Community NPIs the Annual Report provides two types of
indicators (Counts of Change and Rates of Change). Based on the community-level work in which the CSBG
Eligible Entity is engaged, select the appropriate NPIs in either section. All the NPIs are optional and a category of
“other” exists for a CSBG Eligible Entity to create its own indicator if none of those provided captures what the
CSBG Eligible Entity is trying to achieve.
The first way to report impact is the Counts of Change indicators. These are basic measures that provide the
number of units being measured, e.g. jobs, houses, resources, etc. that have been added (created) or subtracted
(eliminated), and in some cases maintained, in the community the CSBG Eligible Entity has targeted.
The second way to report impact is the Rates of Change indicators. While requiring a bit more information, these
indicators tell the full story of the magnitude of the impact a community initiative (usually involving multiple
organizations) has had in a community.
FRN #2 –CSBG Annual Report
October 2016 Module 3, Instructional Notes Page 31 of 66

Instructional Notes
Module 3 - Community Level
In the Rates of Change section, the measures call for reporting the “percent change”—the increase or decrease of
something from one year to the next. Please see the examples below.
Example 1: If you are measuring a percent increase in shelter beds, you would provide the following
information:
II.) Baseline existing starting point used for comparisons (#): Total Number of shelter beds (last year)
III.) Target (#): Targeted Number of shelter beds
V.) Actual Results (#): Actual number of shelter beds for the year
Example 2: If you are measuring a percent increase in the high school graduation rate in the identified
community (in this case one school district), you would provide the following information:
II.) Baseline existing starting point used for comparisons (#): High School Graduation Rate (last year)
III.) Target (#): Targeted High School Graduation Rate
V.) Actual Results (#): Actual High School Graduation Rate (at the end of the initiative)
The calculation for a percent increase or decrease for the community NPI rates of change is auto calculated in
column VI (actual percent change from baseline). The same logic applies when reporting a percent decrease.
Note, outcomes will only be reported once a community initiative has been reached or when progress has been
made toward the ultimate expected outcome. If progress has not been made, there is a place to identify this in
the Community Initiative Status Form.
Assistance with these types of calculations can either be obtained locally or from the national partners.
Module 3, Section C: Community Strategies List
CSBG Eligible Entities will use the Community Strategies field provided in the Community Initiative Status form to
identify relevant strategies community level initiative. A complete listing of the Community Strategies is found in
Section C. The Community Strategies List provides a basic identification of strategies, arranged by Domain and by
topic area. The list cannot be all-inclusive, as such an “other” category is included. This standardized list will aid
in local and state analysis of the relationship between community-level strategies and outcomes.
FRN #2 –CSBG Annual Report
October 2016 Module 3, Instructional Notes Page 32 of 66

Module 3, Section A: Community Initiative Status Form
Name of CSBG Eligible Entity Reporting:
Use the dropdown menu to select the response where appropriate.
1. Initiative Name
2. Initiative Year 1-7+ years
3. Problem Identification Narrative
(Provide a narrative on the scope of the problem)
4. Goal/Agenda Narrative
(Provide a narrative on the goal/agenda)
5. Issue/CSBG Community Employment; Education and Cognitive Development; Income, Infrastructure,
Domains and Asset Building; Housing; Health and Social/Behavioral Development; or Civic
Engagement and Community Involvement
6. Ultimate Expected Outcome Community Level National Performance Indicators (NPIs)
(Reference the Community NPIs listed in Section B)
7. Identified Community
Neighborhood, City, School District, County, Service Area, State, Region, or Other
8. Expected Duration Narrative
(Provide the range in years, e.g. 1-3 years)
9. Partnership Type Independent CAA Initiative, CAA is the core organizer of multi-partner Initiative,
or CAA is one of multiple active investors and partners
10. Partners Narrative
(Provide a narrative on the key 1-3 partners)
11. Strategy(ies)
Select from the Community Level Strategies listed in Section C
12. Progress on
Outcomes/Indicators No Outcomes to Report, Interim Outcomes, Final Outcomes
13. Impact of Outcomes Narrative
(Provide additional information on the scope of the impact of these outcomes.
e.g. If an initiative created a health clinic, please describe how many individuals
and families are expected to be impacted.)
14. Outcomes/Indicators to Community Level National Performance Indicators (NPIs)
Report (Reference the Community NPIs listed in Section B)
15. Final Status Initiative Active, Initiative Ended Early, Initiative Ended as Planned, Completed
Still Delivering Value
16. Lessons Learned
Narrative
October 2016 Module 3, Section A: Community Initiative Status Form Page 33 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Employment Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Employment Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
Counts
1. Number of jobs created to increase opportunities for people with low incomes in the identified community.
of
Change 2. Number of job opportunities maintained in the identified community.
3. Number of “living wage ” jobs created in the identified community*.
4. Number of “living wage” jobs maintained in the identified community*.
5. Number of jobs created in the identified community with a benefit package.
*When reporting on indicators related to living wage, agencies can provide their own definition or select from national or locally-defined models. Please indicate the living wage definition used in the General Comment box.
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Employment Indicators - Please specify below. Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
Counts of
Change
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Employment Indicators (auto-populated) point used for baseline baseline (% auto calculated)
Rates of comparisons (Target % auto (% auto
Change (#) calculated) calculated)
1. Percent decrease of the unemployment rate.
2. Percent decrease of the youth unemployment rate.
3. Percent decrease of the underemployment rate.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Other Other Rates of Change for Employment Indicators (auto-populated) point used for baseline baseline (% auto calculated)
- Please specify below. comparisons (Target % auto (% auto
Rates of (#) calculated) calculated)
Change
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Employment Page 34 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Education and Cognitive Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Education and Cognitive Development Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
1. Number of accessible and affordable early childhood or pre-school education assets or resources added to the
identified community.
2. Number of accredited or licensed affordable child care facilities added in the identified community.
3. Number of new Early Childhood Screenings offered to children (ages 0-5) of families with low-incomes in the
Counts identified community.
of
Change 4. Number of accessible and affordable education assets or resources added for school age children in the
identified community. (e.g., academic, enrichment activities, before/after school care, summer programs)
5. Number of accessible and affordable post secondary education assets or resources added for newly graduating
youth in the identified community. (e.g. college tuition, scholarships, vocational training, etc.)
6. Number of accessible and affordable basic or secondary education assets or resources added for adults in the
identified community. (e.g. literacy, ESL, ABE/GED, etc.)
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Education and Cognitive Development Indicators - Please specify below. Community (#) Results target accuracy
Counts of (auto-populated) (#) (% auto calculated)
Change
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Education and Cognitive Development Page 35 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Education and Cognitive Development Indicators
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Education and Cognitive Development (auto-populated) point used for baseline baseline (% auto calculated)
Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
1. Percent increase of children in the identified community who
are kindergarten ready.
2. Percent increase of children in the identified community at (or
above) the basic reading level.
3. Percent increase of children in the identified community at (or
above) the basic math level.
Rates of
Change 4. Percent increase in high school (or high school equivalency)
graduation rate in the identified community.
5. Percent increase of the rate of youth in the identified
community who attend post-secondary education.
6. Percent increase of the rate of youth in the identified
community who graduate from post-secondary education.
7. Percent increase of adults in the identified community who
attend post-secondary education.
8. Percent increase of adults in the identified community who
graduate from post-secondary education.
9. Percent increase in the adult literacy rate in the identified
community .
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Education and Cognitive Community existing starting (#) change from (#) change from target accuracy
Other Development Indicators (auto populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
Change (#) calculated) calculated)
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Education and Cognitive Development Page 36 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Infrastructure and Asset Building Indicators
Name of CSBG Eligible Entity Reporting:
Counts of Change for Infrastructure and Asset I.) Identified II.) Target III.) Actual IV.) Performance
Community (#) Results target accuracy
Building Indicators (auto-populated) (#) (% auto calculated)
1. Number of new accessible assets/resources created in the identified community:
a. Commercial
b. Financial
c. Technological/ Communications (e.g.
broadband)
Counts d. Transportation
of e. Recreational (e.g. parks, gardens, libraries)
Change f. Other Public Assets/Physical Improvements
2. Number of existing assets/resources made accessible to the identified community:
a. Commercial
b. Financial
c. Technological/ Communications (e.g.
broadband)
d. Transportation
e. Recreational (e.g. parks, gardens, libraries)
f. Other Public Assets/Physical Improvements
Other Counts of Change for Infrastructure and Asset I.) Identified II.) Target III.) Actual IV.) Performance
Other Community (#) Results target accuracy
Counts of Building Indicators - Please specify below. (auto populated) (#) (% auto calculated)
Change
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Infrastructure and Asset Building Page 37 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Housing Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Housing Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
1. Number of safe and affordable housing units developed in the identified community (e.g. built or set aside units
Counts for people with low incomes).
of 2. Number of safe and affordable housing units maintained and/or improved through WAP or other rehabilitation
Change efforts in the identified community.
3. Number of shelter beds created in the identified community.
4. Number of shelter beds maintained in the identified community.
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Housing Indicators- Please specify below. Community (#) Results target accuracy
Counts of (auto-populated) (#) (% auto calculated)
Change
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Housing Indicators (auto-populated) point used for baseline baseline (% auto calculated)
comparisons (Target % auto (% auto
(#) calculated) calculated)
1. Percent decrease in the rate of homelessness in the identified
Rates of community.
Change 2. Percent decrease in the foreclosure rate in the identified
community.
3. Percent increase in the rate of home ownership of people with
low incomes in the identified community.
4. Percent increase of affordable housing in the identified
community.
5. Percent increase of shelter beds in the identified community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Community existing starting (#) change from (#) change from target accuracy
Other Rates of Change for Housing Indicators (auto populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
Change (#) calculated) calculated)
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Housing Page 39 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Health and Social/Behavioral Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Health and Social/Behavioral Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
1. Number of accessible and affordable physical health assets or resources created in the identified community.
Counts
of 2. Number of accessible and affordable behavioral and mental health assets or resources created in the identified community.
Change
3. Number of public safety assets and resources created in the identified community.
4. Number of accessible and affordable healthy food resources created in the identified community.
5. Number of activities designed to improve police and community relations within the identified community.
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Health and Social/Behavioral Indicators- Please specify below. Community (#) Results target accuracy
Counts of (auto-populated) (#) (% auto calculated)
Change
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing (#) change from (#) change from target accuracy
Rates of Change for Physical Health, Wellbeing, and (auto-populated) starting point baseline baseline (% auto calculated)
Development Indicators used for (Target % auto (% auto
comparisons calculated) calculated)
(#)
1. Percent decrease in infant mortality rate in the identified community.
Rates of
Change 2. Percent decrease in childhood obesity rate in the identified
community.
3. Percent decrease in adult obesity rate in the identified community.
4. Percent increase in child immunization rate in the identified
community.
5. Percent decrease in uninsured families in the identified community.
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Health and Social/Behavioral Page 40 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Health and Social/Behavioral Indicators
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing (#) change from (#) change from target accuracy
Rates of Change for Behavioral and Mental health, Emotional (auto-populated) starting point baseline baseline (% auto calculated)
Wellbeing, and Development Indicators used for (Target % auto (% auto
comparisons calculated) calculated)
(#)
1. Percent decrease in the teen pregnancy rate in the identified
community.
2. Percent decrease in unplanned pregnancies in the identified
community.
Rates of 3. Percent decrease in substance abuse rate in the identified
Change community.(e.g. cigarettes, prescription drugs, narcotics, alcohol).
4. Percent decrease in domestic violence rate in the identified
community.
5. Percent decrease in the child abuse rate in the identified community.
6. Percent decrease in the child neglect rate in the identified community.
7. Percent decrease in the elder abuse rate in the identified community.
8. Percent decrease in the elder neglect rate in the identified
community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing (#) change from (#) change from target accuracy
Rates of Change for Public Safety Indicators (auto populated) starting point baseline baseline (% auto calculated)
used for (Target % auto (% auto
comparisons calculated) calculated)
(#)
Rates of 1. Percent decrease in recidivism rate in the identified community.
Change
2. Percent decrease in non-violent crime rate in the identified
community.
3. Percent decrease in violent crime rate in the identified community.
4. Percent decrease in teens involved with the juvenile court system in
the identified community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Health and Social/Behavioral Community existing (#) change from (#) change from target accuracy
Other Indicators (auto populated) starting point baseline baseline (% auto calculated)
Rates of - Please specify below. used for (Target % auto (% auto
Change comparisons calculated) calculated)
(#)
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Health and Social/Behavioral Page 41 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Civic Engagement and Community Involvement Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Civic Engagement and Community (auto-populated) point used for baseline baseline (% auto calculated)
Involvement Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
1. Percent increase of donated time to support the CSBG Eligible Entity's
delivery of services and/or implementation of strategies to address
Rates of conditions of poverty in the identified community.
Change 2. Percent increase of donated resources to support the CSBG Eligible
Entity's delivery of services and/or implementation of strategies to
address conditions of poverty in the identified community.
3. Percent increase of people participating in public hearings, policy
forums, community planning, or other advisory boards related to the
CSBG Eligible Entity's delivery of service and/or implementation of
strategies to address conditions of poverty in the identified community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Civic Engagement and Community Community existing starting (#) change from (#) change from target accuracy
Other Involvement Indicators (auto-populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
(#) calculated) calculated)
Change
General comments:
FRN #2 –CSBG Annual Report
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Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 3: People with low-incomes are engaged and active in building opportunities in communities.
Civic Engagement and Community Involvement Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Civic Engagement and Community (auto-populated) point used for baseline baseline (% auto calculated)
Involvement Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
Rates of
Change 1. Percent increase of people with low incomes who support the CSBG
Eligible Entity's delivery of service and/or implementation of strategies
to address conditions of poverty in the identified community.
2. Percent increase of people with low incomes who acquire and
maintain leadership roles with the CSBG Eligible Entity or other
organizations within the identified community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Civic Engagement and Community Community existing starting (#) change from (#) change from target accuracy
Other Involvement Indicators (auto-populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
(#) calculated) calculated)
Change
General comments:
FRN #2 –CSBG Annual Report
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Module 3, Section C: Community Strategies List
Employment Strategies
Minimum/Living Wage Campaign
Job Creation/Employment Generation
Job Fairs
Earned Income Tax Credit (EITC) Promotion
Commercial Space Development
Employer Education
Employment Policy Changes
Employment Legislative Changes
Other Employment Strategy: (please specify)
Education and Cognitive Development Strategies
Preschool for All Campaign
Charter School Development
After School Enrichment Activities Promotion
Pre K-College/Community College Support
Children’s Trust Fund Creation
Scholarship Creation
Child Tax Credit (CTC) Promotion
Adoption Child Care Quality Rating
Adult Education Establishment
Education and Cognitive Development Policy Changes
Education and Cognitive Development Legislative Changes
Other Education and Cognitive Development Strategy: (please specify)
Infrastructure and Asset Building Strategies
Cultural Asset Creation
Police/Community Relations Campaign
Neighborhood Safety Watch Programs
Anti-Predatory Lending Campaign
Asset Building and Savings Promotion
Develop/Build/Rehab Spaces
Maintain or Host Income Tax Preparation Sites
Community-Wide Data Collection Systems Development
Local 211 or Resource/Referral System Development
Water/Sewer System Development
Community Financial Institution Creation
Infrastructure Planning Coalition
Park or Recreation Creation and Maintenance
Rehabilitation/Weatherization of Housing Stock
Community Center/Community Facility Establishment
Asset Limit Barriers for Benefits Policy Changes
Infrastructure and Asset Building Policy Changes
Infrastructure and Asset Building Legislative Changes
Other Infrastructure and Asset Building Strategy: (please specify)
FRN #2 – CSBG Annual Report
October 2016 Module 3, Section C: Community Strategies List Page 44 of 66

Module 3, Section C: Community Strategies List
Housing Strategies
End Chronic Homelessness Campaign
New Affordable Single Unit Housing Creation
New Affordable Multi- Unit Housing Creation (Single Resident Occupancy (SRO), temporary housing, transitional housing)
Tenants’ Rights Campaign
New Shelters Creation (including day shelters and domestic violence shelters)
Housing or Land Trust Creation
Building Codes Campaign
Housing Policy Changes
Housing Legislative Changes
Other Housing Strategy: (please specify)
Health and Social/Behavioral Development Strategies
Health Specific Campaign
Farmers Market or Community Garden Development
Grocery Store Development
Gun Safety/Control Campaign
Healthy Food Campaign
Nutrition Education Collaborative
Food Bank Development
Domestic Violence Court Development
Drug Court Development
Alternative Energy Source Development
Develop or Maintain a Health Clinic
Health and Social/Behavioral Development Policy Changes
Health and Social/Behavioral Development Legislative Changes
Other Health and Social/Behavioral Development Strategy: (please specify)
Community Support Strategies
Off-Hours (Non-Traditional Hours) Child Care Development
Transportation System Development
Transportation Services Coordination and Support
Community Support Policy Changes
Community Support Legislative Changes
Other Community Support Strategy: (please specify)
Emergency Management Strategies
State or Local Emergency Management Board Enhancement
Community wide Emergency Disaster Relief Service Creation
Disaster Preparation Planning
Emergency Management Policy Changes
Emergency Management Legislative Changes
Other Emergency Management Strategy: (please specify)
FRN #2 – CSBG Annual Report
October 2016 Module 3, Section C: Community Strategies List Page 45 of 66

Module 3, Section C: Community Strategies List
Civic Engagement and Community Involvement Strategies- Goal 2
Development of Health and Social Service Provider Partnerships
Recruiting and Coordinating Community Volunteers
Poverty Simulations
Attract Capital Investments
Build/Support Increased Equity
Equity Awareness Campaign
Coordinated Community-wide Needs Assessment
Civic Engagement and Community Involvement in Advocacy Efforts
Civic Engagement Policy Changes
Civic Engagement Legislative Changes
Other Civic Engagement and Community Involvement Strategy: (please specify)
Civic Engagement and Community Involvement Strategies — Goal 3
Empowerment of Individuals/Families with Low-Incomes
Campaign to Ensure Individuals with Low-Incomes are Represented on Local Governing Bodies
Social Capital Building Campaign for Individuals/Families with Low-Incomes
Campaign for Volunteer Placement and Coordination
Civic Engagement Policy Changes
Civic Engagement Legislative Changes
Other Civic Engagement and Community Involvement Strategy: (please specify)
FRN #2 – CSBG Annual Report
October 2016 Module 3, Section C: Community Strategies List Page 46 of 66

Module 4
Individual and Family Level
Page 47 of 66

Instructional Notes
Module 4 - Individual and Family Level
Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
All Individual and Family NPIs are optional there is a category for "Other Outcome Indicator". CSBG Eligible
Entities will only report an "Other Outcome Indicator" if the current NPIs do not capture the outcomes the CSBG
Eligible Entity is trying to achieve. Sample language is provided in the “Other Outcome Indicator” data entry
section and will be modified by the CSBG Eligible Entity as necessary.
Please see additional notes below:
For All Individual and Family Domains:
Targeting: Targets are set in the Community Action Plan and are identified through the planning phase of the
CAA’s ROMA (Results Oriented Management and Accountability) cycle. The following will be repotred for every
indicator:
Column I: Number of Participants Served
Column II: Target (number planned to achieve an outcome in the reporting period)
Column III: Actual Results (actual number of participants who achieved the outcome)
Please note, it is rare that 100% of the people served will achieve the proposed outcome.
Domain Specific Instructions:
Employment, Income and Asset Building, and Housing Domains
Indicators tracking outcomes for 90 or 180 days: CSBG Eligible Entities are only expected to report on
indicators with retention time frames for programs that specifically include follow up. If the CSBG Eligible
Entity does not conduct follow up activities as a part of their programs, outcomes for indicators with retention
time frames will not be reported.
Employment Domain
NPI 5-7: When reporting on indicators related to living wage, CSBG Eligible Entities can provide their own
definition or select from national or locally-defined models. Please idenitfy the living wage definition used in
the General Comments Section.
Income and Asset Building Domain
NPI 1 and 2: CSBG Eligible Entities are only expected to report on basic needs indicators as applicable to the
CSBG Eligible Entity's programs. When reporting on indicators related to basics needs, CSBG Eligible Entities
can provide their own definition or select from national or locally-defined models. Please idenitfy the basic
needs definition used in the General Comments Section.
NPI 8: This indicator requires agencies to keep an unduplicated count of people who report improved financial
well-being based on responses to the CFPB Financial Well Being Scale (found in the link below)
http://www.consumerfinance.gov/reports/financial-well-being-scale/
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October 2016 Module 4, Instructional Notes Page 48 of 66

Instructional Notes
Module 4 - Individual and Family Level
Outcomes Across Multiple Domains:
The data from this indicator will help tell the story of how many lives were improved because of the CSBG
Network. Reporting on this indicator requires CSBG Eligible Entities to keep an unduplicated count of
individuals who achieved one or more outcomes reported in the NPIs.
Module 4, Section B: Individual and Family Services - Data Entry Form
CSBG Eligible Entities will report unduplicated counts of individuals receiving any of the services listed on the
Individual and Family Services form. This standardized Individual and Family Services list will aid in analysis of the
relationship between people, services, and outcomes.
Module 4, Section C: All Characteristics Report - Data Entry Form
The All Characteristics Report collects data on all individuals and households, whether or not funded directly
by CSBG. This demographic information will strengthen the CSBG Annual Report by demonstrating who is
being served by CSBG Eligible Entities.
To obtain unduplicated counts, a CSBG Eligible Entity will need to have a system that distinguishes the
characteristics for each individual/household. While some individuals and households may be served by
several programs within a reporting year and entered into multiple data systems (e.g. LIHEAP, WIC, etc.), they
must be reported as unduplicated individuals (in row A) and unduplicated households (in row B) in this report.
Please note, a single person is reported as an unduplicated individual and an unduplicated household.
We recognize that CSBG Eligible Entities have multiple data systems and may not be able to have an
unduplicated count across several systems. If you are unable to collect any characteristics on unduplicated
individuals or households due to data systems issues, include those individuals in row E and households in row
F at the end of this report. Additionally, please indicate the programs in which these individuals and
households were enrolled. The system will allow mutliple programs to be added.
FRN #2 –CSBG Annual Report
October 2016 Module 4, Instructional Notes Page 49 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Employment Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Employment in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
1. The number of unemployed youth who obtained
employment to gain skills or income.
2. The number of unemployed adults who obtained
employment (up to a living wage).
3. The number of unemployed adults who obtained and
maintained employment for at least 90 days
(up to a living wage).
4. The number of unemployed adults who obtained and
maintained employment for at least 180 days
(up to a living wage).
5. The number of unemployed adults who obtained
employment (with a living wage or higher).
6. The number of unemployed adults who obtained and
maintained employment for at least 90 days
(with a living wage or higher).
7. The number of unemployed adults who obtained and
maintained employment for at least 180 days
(with a living wage or higher).
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Employment in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
8. The number of employed participants in a career-
advancement related program who entered or
transitioned into a position that provided increased
income and/or benefits.
a. Of the above, the number of employed participants
who Increased income from employment through
wage or salary amount increase.
b. Of the above, the number of employed participants
who increased income from employment through
hours worked increase.
c. Of the above, the number of employed participants
who increased benefits related to employment.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Other Employment Outcome Indicator in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
9. The number of individuals or households
.
Comments:
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October 2016 Module 4, Section A: Individual and Family NPIs - Employment Page 50 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Education and Cognitive Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Education and Cognitive Development Served Outcome (III/II = V] (% auto
in program(s) (#) [III/ I = IV ] (% calculated)
auto calculated)
1. The number of children (0 to 5) who demonstrated improved
emergent literacy skills.
2. The number of children (0 to 5) who demonstrated skills for
school readiness.
3. The number of children and youth who demonstrated improved
positive approaches toward learning, including improved attention
skills. (auto total).
a. Early Childhood Education (ages 0-5)
b. 1st grade-8th grade
c. 9th grade-12th grade
4. The number of children and youth who are achieving at basic
grade level (academic, social, and other school success skills). (auto
total)
a. Early Childhood Education (ages 0-5)
b. 1st grade-8th grade
c. 9th grade-12th grade
5. The number of parents/caregivers who improved their home
environments.
6. The number of adults who demonstrated improved basic
education.
7. The number of individuals who obtained a high school diploma
and/or obtained an equivalency certificate or diploma.
8. The number of individuals who obtained a recognized credential,
certificate, or degree relating to the achievement of educational or
vocational skills.
9. The number of individuals who obtained an Associate’s degree.
10. The number of individuals who obtained a Bachelor’s degree.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Education and Cognitive Development Outcome Served Outcome (III/II = V] (% auto
Indicator in program(s) (#) [III/ I = IV ] (% calculated)
auto calculated)
11. The number of individuals or households .
Comments:
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October 2016 Module 4, Section A: Individual and Family NPIs - Education Page 51 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Health and Social/Behavioral Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Health and Social/Behavioral Development calculated)
in program(s) (#) [III/ I = IV ] (% auto
calculated)
1. The number of individuals who demonstrated increased
nutrition skills (e.g. cooking, shopping, and growing food).
2. The number of individuals who demonstrated improved
physical health and well-being.
3. The number of individuals who demonstrated improved
mental and behavioral health and well-being.
4. The number of individuals who improved skills related
to the adult role of parents/ caregivers.
5. The number of parents/caregivers who demonstrated
increased sensitivity and responsiveness in their
interactions with their children.
6. The number of seniors (65+) who maintained an
independent living situation.
7. The number of individuals with disabilities who
maintained an independent living situation.
8. The number of individuals with chronic illness who
maintained an independent living situation.
9. The number of individuals with no recidivating event for
six months.
a. Youth (ages 14-17)
b. Adults (ages 18+)
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Health and Social/Behavioral Development Served Outcome (III/II = V] (% auto
Outcome Indicator in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
10. The number of individuals or households
.
Comments:
FRN #2 – CSBG Annual Report
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Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable
and achieve economic security.
Employment Services
Name of CSBG Eligible Entity Reporting:
Employment Services Unduplicated Number of
Individuals Served
Skills Training and Opportunities for Experience
Vocational Training
On-the-Job and other Work Experience
Youth Summer Work Placements
Apprenticeship/Internship
Self-Employment Skills Training
Job Readiness Training
Career Counseling
Workshops
Coaching
Job Search
Coaching
Resume Development
Interview Skills Training
Job Referrals
Job Placements
Pre-employment physicals, background checks, etc.
Post Employment Supports
Coaching
Interactions with employers
Employment Supplies
Employment Supplies
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Employment Services Page 57 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable
and achieve economic security.
Education and Cognitive Development Services
Name of CSBG Eligible Entity Reporting:
Education and Cognitive Development Services Unduplicated Number of
Individuals Served
Child/Young Adult Education Programs
Early Head Start
Head Start
Other Early-Childhood (0-5 yr. old) Education
K-12 Education
K-12 Support Services
Financial Literacy Education
Literacy/English Language Education
College-Readiness Preparation/Support
Other Post Secondary Preparation
Other Post Secondary Support
School Supplies
School Supplies
Extra-curricular Programs
Before and After School Activities
Summer Youth Recreational Activities
Summer Education Programs
Behavior Improvement Programs (attitude, self-
esteem, Dress-for-Success, etc.)
Mentoring
Leadership Training
Adult Education Programs
Adult Literacy Classes
English Language Classes
Basic Education Classes
High School Equivalency Classes
Leadership Training
Parenting Supports (may be a part of the early
childhood programs identified above)
Applied Technology Classes
Post-Secondary Education Preparation
Financial Literacy Education
Post-Secondary Education Supports
College applications, text books, computers, etc.
Financial Aid Assistance
Scholarships
Home Visits
Home Visits
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Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and
achieve economic security.
Income and Asset Building Services
Name of CSBG Eligible Entity Reporting:
Income and Asset Building Services Unduplicated Number of
Individuals Served
Training and Counseling Services
Financial Capability Skills Training
Financial Coaching/Counseling
Financial Management Programs (including budgeting, credit
management, credit repair, credit counseling, etc.)
First-time Homebuyer Counseling
Foreclosure Prevention Counseling
Small Business Start-Up and Development Counseling
Sessions/Classes
Benefit Coordination and Advocacy
Child Support Payments
Health Insurance
Social Security/SSI Payments
Veteran's Benefits
TANF Benefits
SNAP Benefits
Asset Building
Saving Accounts/IDAs and other asset building accounts
Other financial products (IRA accounts, MyRA, other
retirement accounts, etc.)
VITA, EITC, or Other Tax Preparation programs
Loans And Grants
Micro-loans
Business incubator/business development loans
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Module 4, Section B: Individual and Family Services - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve
economic security.
Housing Services
Name of CSBG Eligible Entity Reporting:
Housing Services Unduplicated Number of
Individuals Served
Housing Payment Assistance
Financial Capability Skill Training
Financial Coaching/Counseling
Rent Payments (includes Emergency Rent Payments)
Deposit Payments
Mortgage Payments (includes Emergency Mortgage Payments)
Eviction Prevention Services
Eviction Counseling
Landlord/Tenant Mediations
Landlord/Tenant Rights Education
Utility Payment Assistance
Utility Payments (LIHEAP-includes Emergency Utility Payments)
Utility Deposits
Utility Arrears Payments
Level Billing Assistance
Housing Placement/Rapid Re-housing
Temporary Housing Placement (includes Emergency Shelters)
Transitional Housing Placements
Permanent Housing Placements
Rental Counseling
Housing Maintenance & Improvements
Home Repairs (e.g. structural, appliance, heating systems. etc.)
(Including Emergency Home Repairs)
Weatherization Services
Independent-living Home Improvements (e.g. ramps, tub and
shower grab bars, handicap accessible modifications, etc.)
Healthy Homes Services(e.g. reduction or elimination of lead,
radon, carbon dioxide and/or fire hazards or electrical issues,
etc.)
Energy Efficiency Improvements (e.g. insulation, air sealing,
furnace repair, etc.)
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Housing Services Page 60 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and
achieve economic security.
Health and Social/Behavioral Development
Name of CSBG Eligible Entity Reporting:
Health and Social/Behavioral Development Services Unduplicated Number of
Individuals Served
Health Services, Screening and Assessments
Immunizations
Physicals
Developmental Delay Screening
Vision Screening
Prescription Payments
Doctor Visit Payments
Maternal/Child Health
Nursing Care Sessions
In-Home Affordable Seniors/Disabled Care Sessions
(Nursing, Chores, Personal Care Services)
Health Insurance Options Counseling
Reproductive Health Services
Coaching Sessions
Family Planning Classes
Contraceptives
STI/HIV Prevention Counseling Sessions
STI/HIV Screenings
Wellness Education
Wellness Classes (stress reduction, medication management,
mindfulness, etc.)
Exercise/Fitness
Mental/Behavioral Health
Detoxification Sessions
Substance Abuse Screenings
Substance Abuse Counseling
Mental Health Assessments
Mental Health Counseling
Crisis Response/Call-In Responses
Domestic Violence Programs
Support Groups
Substance Abuse Support Group Meetings
Domestic Violence Support Group Meetings
Mental Health Support Group Meeting
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Module 4, Section C: All Characteristics Report - Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.
Name of CSBG Eligible Entity Reporting:
A. Total unduplicated number of all INDIVIDUALS about whom one or more characteristics were obtained:
B. Total unduplicated number of all HOUSEHOLDS about whom one or more characteristics were obtained:
C. INDIVIDUAL LEVEL CHARACTERISTICS
1. Gender Number of Individuals 6. Ethnicity/Race Number of Individuals
a. Male I. Ethnicity
b. Female a. Hispanic, Latino or Spanish Origins
c. Other b. Not Hispanic, Latino or Spanish Origins
d. Unknown/not reported c. Unknown/not reported
TOTAL (auto calculated) 0 TOTAL (auto calculated) 0
2. Age Number of Individuals II. Race
a. 0-5 a. American Indian or Alaska Native
b. 6-13 b. Asian
c. 14-17 c. Black or African American
d. 18-24 d. Native Hawaiian and Other Pacific Islander
e. 25-44 e. White
f. 45-54 f. Other
g. 55-59 g. Multi-race (two or more of the above)
h. 60-64 h. Unknown/not reported
i. 65-74 TOTAL (auto calculated) 0
j. 75+
k. Unknown/not reported 7. Military Status Number of Individuals
TOTAL (auto calculated) 0 a. Veteran
b. Active Military
3. Education Levels Number of Individuals c. Unknown/not reported
[ages 14-24] [ages 25+] TOTAL (auto calculated) 0
a. Grades 0-8
b. Grades 9-12/Non-Graduate 8. Work Status (Individuals 18+) Number of Individuals
c. High School Graduate/ Equivalency Diploma a. Employed Full-Time
d. 12 grade + Some Post-Secondary b. Employed Part-Time
e. 2 or 4 years College Graduate c. Migrant Seasonal Farm Worker
f. Graduate of other post-secondary school d. Unemployed (Short-Term, 6 months or less)
g. Unknown/not reported e. Unemployed (Long-Term, more than 6 months)
TOTAL (auto calculated) 0 0 f. Unemployed (Not in Labor Force)
g. Retired
4. Disconnected Youth Number of Individuals h. Unknown/not reported
a. Youth ages 14-24 who are neither working or in school TOTAL (auto calculated) 0
5. Health Number of Individuals
Yes No Unknown
a. Disabling Condition
Yes No Unknown
b. Health Insurance*
*If an individual reported that they had Health Insurance please identify the source of health
insurance below.
Health Insurance Sources
i. Medicaid
ii. Medicare
iii. State Children’s Health Insurance Program
iv. State Health Insurance for Adults
v. Military Health Care
vi. Direct-Purchase
vii. Employment Based
viii. Unknown/not reported
TOTAL (auto calculated) 0
FRN #2 – CSBG Annual Report Page 65 of 66
October 2016 Module 4, Section C: All Characteristics Report

Module 4, Section C: All Characteristics Report - Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.
Name of CSBG Eligible Entity Reporting:
D. HOUSEHOLD LEVEL CHARACTERISTICS
9. Household Type Number of Households 13. Sources of Household Income Number of Households
a. Single Person a. Income from Employment Only
b. Two Adults NO Children b. Income from Employment and Other Income Source
c. Single Parent Female c. Income from Employment, Other Income Source,
d. Single Parent Male and Non-Cash Benefits
e. Two Parent Household d. Income from Employment and Non-Cash Benefits
f. Non-related Adults with Children e. Other Income Source Only
g. Multigenerational Household f. Other Income Source and Non-Cash Benefits
h. Other g. No Income
i. Unknown/not reported h. Non-Cash Benefits Only
TOTAL (auto calculated) 0 i. Unknown/not reported
TOTAL (auto calculated) 0
10. Household Size Number of Households Below, please report the types of Other income and/or non-cash benefits received by
a. Single Person the households who reported sources other than employment
b. Two 14. Other Income Source Number of Households
c. Three a. TANF
d. Four b. Supplemental Security Income (SSI)
e. Five c. Social Security Disability Income (SSDI)
f. Six or more d. VA Service-Connected Disability Compensation
g. Unknown/not reported e. VA Non-Service Connected Disability Pension
TOTAL (auto calculated) 0 f. Private Disability Insurance
g. Worker’s Compensation
11. Housing Number of Households h. Retirement Income from Social Security
a. Own i. Pension
b. Rent j. Child Support
c. Other permanent housing k. Alimony or other Spousal Support
d. Homeless l. Unemployment Insurance
e. Other m. EITC
f. Unknown/not reported n. Other
TOTAL (auto calculated) 0 o. Unknown/not reported
12. Level of Household Income Number of Households 15. Non-Cash Benefits Number of Households
(% of HHS Guideline) a. SNAP
a. Up to 50% b. WIC
b. 51% to 75% c. LIHEAP
c. 76% to 100% d. Housing Choice Voucher
d. 101% to 125% e. Public Housing
e. 126% to 150% f. Permanent Supportive Housing
f. 151% to 175% g. HUD-VASH
g. 176% to 200% h. Childcare Voucher
h. 201% to 250% i. Affordable Care Act Subsidy
i. 250% and over j. Other
j. Unknown/not reported k. Unknown/not reported
TOTAL (auto calculated) 0
Number of Individuals Not Included in the Totals Above (due to data collection system integration barriers)
Please list the unduplicated number of INDIVIDUALS served in each program*:
Program Name Number of Individuals
Number of Households Not Included in the Totals Above (due to data collection system integration barriers)
Please list the unduplicated number of HOUSEHOLDS served in each program*:
Program Name Number of Households
FRN #2 – CSBG Annual Report Page 66 of 66
October 2016 Module 4, Section C: All Characteristics Report

Module 4
Individual and Family Level
ROMA Catalogue

Page 47 of 66

Instructional Notes
Module 4 –ROMA - Individual and
Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
All Individual and Family NPIs are optional there is a category for "Other Outcome Indicator". CSBG Eligible
Entities will only report an "Other Outcome Indicator" if the current NPIs do not capture the outcomes the CSBG
Eligible Entity is trying to achieve. Sample language is provided in the “Other Outcome Indicator” data entry
section and will be modified by the CSBG Eligible Entity as necessary.
Please see additional notes below:
For All Individual and Family Domains:
Targeting: Targets are set in the Community Action Plan and are identified through the planning phase of the
CAA’s ROMA (Results Oriented Management and Accountability) cycle. The following will be repotred for every
indicator:
Column I: Number of Participants Served
Column II: Target (number planned to achieve an outcome in the reporting period)
Column III: Actual Results (actual number of participants who achieved the outcome)
Please note, it is rare that 100% of the people served will achieve the proposed outcome.
Domain Specific Instructions:
Employment, Income and Asset Building, and Housing Domains
Indicators tracking outcomes for 90 or 180 days: CSBG Eligible Entities are only expected to report on
indicators with retention time frames for programs that specifically include follow up. If the CSBG Eligible
Entity does not conduct follow up activities as a part of their programs, outcomes for indicators with retention
time frames will not be reported.
Employment Domain
NPI 5-7: When reporting on indicators related to living wage, CSBG Eligible Entities can provide their own
definition or select from national or locally-defined models. Please identify the living wage definition used in
the General Comments Section.
Income and Asset Building Domain
NPI 1 and 2: CSBG Eligible Entities are only expected to report on basic needs indicators as applicable to the
CSBG Eligible Entity's programs. When reporting on indicators related to basics needs, CSBG Eligible Entities
can provide their own definition or select from national or locally-defined models. Please identify the basic
needs definition used in the General Comments Section.
NPI 8: This indicator requires agencies to keep an unduplicated count of people who report improved financial
well-being based on responses to the CFPB Financial Well Being Scale (found in the link below)
http://www.consumerfinance.gov/reports/financial-well-being-scale/
FRN #2 –CSBG Annual Report
October 2016 Module 4, Instructional Notes Page 48 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Outcomes Across Multiple Domains:
The data from this indicator will help tell the story of how many lives were improved because of the CSBG
Network. Reporting on this indicator requires CSBG Eligible Entities to keep an unduplicated count of
individuals who achieved one or more outcomes reported in the NPIs.
Employment Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Employment in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
1. The number of unemployed youth who obtained
employment to gain skills or income.
2. The number of unemployed adults who obtained
employment (up to a living wage).
3. The number of unemployed adults who obtained and
maintained employment for at least 90 days
(up to a living wage).
4. The number of unemployed adults who obtained and
maintained employment for at least 180 days
(up to a living wage).
5. The number of unemployed adults who obtained
employment (with a living wage or higher).
6. The number of unemployed adults who obtained and
maintained employment for at least 90 days
(with a living wage or higher).
7. The number of unemployed adults who obtained and
maintained employment for at least 180 days
(with a living wage or higher).
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Employment in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
8. The number of employed participants in a career-
advancement related program who entered or
transitioned into a position that provided increased
income and/or benefits.
a. Of the above, the number of employed participants
who Increased income from employment through
wage or salary amount increase.
b. Of the above, the number of employed participants
who increased income from employment through
hours worked increase.
c. Of the above, the number of employed participants
who increased benefits related to employment.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Other Employment Outcome Indicator in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
9. The number of individuals or households
.
Comments:
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section A: Individual and Family NPIs - Employment Page 50 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Education and Cognitive Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Education and Cognitive Development Served Outcome (III/II = V] (% auto
in program(s) (#) [III/ I = IV ] (% calculated)
auto calculated)
1. The number of children (0 to 5) who demonstrated improved
emergent literacy skills.
2. The number of children (0 to 5) who demonstrated skills for
school readiness.
3. The number of children and youth who demonstrated improved
positive approaches toward learning, including improved attention
skills. (auto total).
a. Early Childhood Education (ages 0-5)
b. 1st grade-8th grade
c. 9th grade-12th grade
4. The number of children and youth who are achieving at basic
grade level (academic, social, and other school success skills). (auto
total)
a. Early Childhood Education (ages 0-5)
b. 1st grade-8th grade
c. 9th grade-12th grade
5. The number of parents/caregivers who improved their home
environments.
6. The number of adults who demonstrated improved basic
education.
7. The number of individuals who obtained a high school diploma
and/or obtained an equivalency certificate or diploma.
8. The number of individuals who obtained a recognized credential,
certificate, or degree relating to the achievement of educational or
vocational skills.
9. The number of individuals who obtained an Associate’s degree.
10. The number of individuals who obtained a Bachelor’s degree.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Education and Cognitive Development Outcome Served Outcome (III/II = V] (% auto
Indicator in program(s) (#) [III/ I = IV ] (% calculated)
auto calculated)
11. The number of individuals or households .
Comments:
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section A: Individual and Family NPIs - Education Page 51 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Health and Social/Behavioral Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Health and Social/Behavioral Development calculated)
in program(s) (#) [III/ I = IV ] (% auto
calculated)
1. The number of individuals who demonstrated increased
nutrition skills (e.g. cooking, shopping, and growing food).
2. The number of individuals who demonstrated improved
physical health and well-being.
3. The number of individuals who demonstrated improved
mental and behavioral health and well-being.
4. The number of individuals who improved skills related
to the adult role of parents/ caregivers.
5. The number of parents/caregivers who demonstrated
increased sensitivity and responsiveness in their
interactions with their children.
6. The number of seniors (65+) who maintained an
independent living situation.
7. The number of individuals with disabilities who
maintained an independent living situation.
8. The number of individuals with chronic illness who
maintained an independent living situation.
9. The number of individuals with no recidivating event for
six months.
a. Youth (ages 14-17)
b. Adults (ages 18+)
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Health and Social/Behavioral Development Served Outcome (III/II = V] (% auto
Outcome Indicator in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
10. The number of individuals or households
.
Comments:
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section A: Individual and Family NPIs - Health and Social/Behavioral Page 54 of 66

I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Outcomes Across Multiple Domains calculated)
in program(s) (#) [III/ I = IV ] (% auto
calculated)
1. The number of individuals who achieved one or more
outcomes as identified by the National Performance
Indicators in various domains.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Other Outcome Indicator in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
2. The number of individuals or households
.

OMB Control No: XXXX-XXXX
Expiration date: XX/XX/XX
SFY-18-K1 Attachment # 2
Community Services Block
Grant (CSBG) Annual Report
OMB PRA Clearance
FRN #2
October 2016

CSBG Annual Report Table of Contents
Module 1 - State Administration… ............................................................................................................... 1
Section A: CSBG Lead Agency, CSBG Authorized Official, CSBG Pointof Contact////////////.2
Section B: Statewide Goals and Accomplishments...////////////////////////////4
Section C: CSBG Eligible Entity Update ............................................................................................. 6
Section D: Organizational Standards for Eligible Entities ...................................................................... 7
Section E: State Use of Funds .............................................................................................................. 10
Section F: State Training and Technical Assistance ............................................................................. 15
Section G: State Linkages and Communication ................................................................................... 17
Section H: Monitoring, Corrective Action, and Fiscal Controls .......................................................... 20
Section I: Results Oriented Management and Accountability (ROMA) System .................................. 22
Module 2 – CSBG Eligible Entity Expenditures, Capacity, and Resources .................................................... 24
Module 2 Instructional Notes////////////////////////////////////////25
Section A: Local Agency CSBG Expenditures. ................................................................................. 26
Section B: Local Agency Capacity Building .......................................................................................... 27
Section C: Local Agency Resources Administered by the CSBG Eligible Entity.................................... 28
Module 3 – Community Level .................................................................................................................... 30
Module 3 Instructional Notes////////////////////////////////////////31
Section A: Community Initiative Status Form ................................................................................ 33
Section B: Community National Performance Indicators (NPIs) .......................................................... 34
Section C: Community Strategies//// ................................................................................. 44
Module 4 - Individual and Family Level ...................................................................................................... 47
Module 4 Instructional Notes////////////////////////////////////////48
Section A: Individual and Family National Performance Indicators (NPIs)///////////////.50
Section B: Individual and Family Services ....................................................................................... 57
Section C: All Characteristics Report////////////////////////////////////.65

Module 2
CSBG Eligible Entity Expenditures,
Capacity, and Resources

Page 24 of 66

Instructional Notes
Module 2 - CSBG Eligible Entity Expenditures, Capacity, and
Resources
Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity - Data Entry Form
Section A: CSBG Expenditures by CSBG Eligible Entity Data Entry Form meets the Congressional requirement
for an explanation of the total amount of CSBG funding expended during the reporting period (identified below)
based on categories referenced in the CSBG Act.
CSBG funding expended during the reporting period should be identified in the domain that best reflects
the services delivered and strategies implemented, as well as the administrative costs associated with the
domains. Further instructions will be provided, but please keep the following in mind, per domain:
Services Supporting Multiple Domains: Expenditures reported under Services Supporting Multiple Domains
are those that span or support outcomes achieved across multiple domains for families and individuals,
such as case management, transportation, and childcare.
Linkages: Many of the activities that were associated with Linkages are now captured in Domain 9: Agency
Capacity Building. This narrows the definition of Linkages, but continues to include community initiatives
and information and referral calls.
Agency Capacity Building: Expenditures for Agency Capacity Building are detailed in Table B on this form.
Reporting on Administration: Administrative costs for CSBG reporting are defined by the Office of
Community Services as “equivalent to typical indirect costs or overhead." As distinguished from program
administration or management expenditures that qualify as direct costs, administrative costs refer to
central executive functions that do not directly support a specific project or service.
Module 2, Section B: CSBG Eligible Entity Capacity Building - Data Entry Form
Section B: CSBG Eligible Entity Capacity Building Data Entry Form provides detail on agency capacity building
funded by CSBG and other funding sources.
Module 2, Section C: Allocated Resources per CSBG Eligible Entity - Data Entry Form
Section C: Allocated Resources per CSBG Eligible Entity data entry form provides data on resources allocated
to, administered through, and generated by the CSBG Eligible Entity. This report provides valuable information
on how CSBG leverages funds from multiple federal, state, local, and private sources as required in the CSBG
Act.
FRN #2 –CSBG Annual Report
October 2016 Module 2, Instructional Notes Page 25 of 66

Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity - Data Entry Form
►Name of CSBG Eligible Entity Reporting:
►A. CSBG Eligible Entity Reporting Period NEW – not asked on Section E "X"
1. July 1 - June 30 ► X
2. October 1 - September 30
3. January 1 - December 31
►B. CSBG Expenditures Domains See Changes and crosswalk matrix – Section E CSBG Funds
1.►Employment SAME
2.►Education and Cognitive Development SAME
3.►Income, Infrastructure, and Asset Building SAME – need to define “Infrastructure”
4.►Housing SAME
5.►Health and Social/Behavioral Development (includes nutrition) ►Moved - Formerly Section E Items 6 + 9,
6. Civic Engagement and Community Involvement – New – Report if available for 2018 ►report in 2019.
Report board activity expense, community-based activities, public events, workshops, community-wide
facilities, recreation and any activities open to the general public that do not require an intake/eligibility
process
7. ►Services Supporting Multiple Domains – New - ►Place Emergency Services and Self-Sufficiency here,
from Section E, Items 5+8. This will be where case management and program management dollars go also.
8.►Linkages (e.g. partnerships that support multiple domains) Moved - Formerly Section E, Items 7. Item 8, - Self-
Sufficiency, eliminated.
►9. Agency Capacity Building (detailed below in Table C) New – Report if available for 2018 the report in
2019.
Report staff training, fundraising, grant writing activities here if available.
10. Other (e.g. emergency management/disaster relief) Report any CSBG Discretionary Emergency Funds here
SAME - Total CSBG Expenditures (auto calculated) $0
Of the CSBG funds reported above, report the total amount used for Administration. For more information on
what qualifies as Administration, refer to IM37. SAME as on Section E.
►C. Details on Agency Capacity Building Activities Funded by CSBG: - NEW
1. Please identify which activities were funded by CSBG under Agency Capacity in Table B. Please check all that apply.
Community Needs Assessment  Data Management & Reporting  Strategic Planning Training & Technical Assistance
Other*
*►Below please specify Other Activities funded by CSBG under Agency Capacity:
October 2016 FRN #2 – CSBG Annual Report Page 26 of 66
Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity

Module 2, Section B: CSBG Eligible Entity Capacity Building - Data Entry Form
►Name of CSBG Eligible Entity:
►A. CSBG Eligible Entity Reporting Period "X"
1. July 1 - June 30
auto-populated from Module
►2. October 1 - September 30 2, Section A
3. January 1 - December 31
B. Hours of Agency Capacity Building (e.g. training, planning, assessment): Hours
NPI – ►1. Hours of Board Members in capacity building activities Closest NPI: 5.1 H. Include also hours
Goal fundraising and meetings where capacity building is discussed or an activity takes place such as a
5.1 partnership event/conference or training.
5.1 ►2. Hours of Agency Staff in capacity building activities Staff Training– Closest NPI – 5.1 G.
C. Volunteer Hours of Agency Capacity Building (e.g. program support, service delivery, fundraising): H
NPI Crosswalk: NPIS Goals 2 and 3
2.3B ►1. Total number of volunteer hours donated to the agency NPI 2.3 B. SAME
3.1 B ►a. Of the above, the total number of volunteer hours donated by individuals with low-incomes NPI
3.1
D. The number of staff who hold certifications that increase agency capacity to achieve family and
Number
community outcomes, as measured by one or more of the following:
NPI Crosswalk:
5.1 B ►1. Number of Nationally Certified ROMA Trainers NPI 5.1 B
None ►2. Number of Nationally Certified ROMA Implementers New - Provide if applicable
5.1 A ►3. Number of Certified Community Action Professionals (CCAP) NPI 5.1 A
5.1 D ►4. Number of Staff with a child development certification NPI 5.1 D
5.1 C ►5. Number of Staff with a family development certification NPI 5.1 C
None 6. Number of Pathways Reviewers New – provide if applicable
None ►7. Number of Staff with Home Energy Professional Certifications WAP Only – NEW provide if applicable
a. Number of Energy Auditors - NEW
b. Number of Retrofit Installer Technicians - NEW
c. Number of Crew Leaders - NEW
d. Number of Quality Control Inspectors (QCI) - NEW
None 8. Number of LEED Risk Certified assessors NEW
None 9. Number of Building Performance Institute (BPI) certified professionals NEW
None 10. Number of Classroom Assessment Scoring System (CLASS) certified professionals NEW
None 11. Number of Certified Housing Quality Standards (HQS) Inspectors NEW
None 12. Number of American Institute of Certified Planners (AICP) NEW
None ►13. Other (Please specify others below): Provide if available (optional)
►E. Number of organizations, both public and private, that the CSBG Eligible Entity actively works with to Unduplicated Number
expand resources and opportunities in order to achieve family and community outcomes: NPIs – Goal 4.1, of Organizations
A-M - SAME. Column II, Number of agreements dropped
Same 1. Non-Profit
Same 2. Faith Based
Same 3. Local Government
Same 4. State Government
Same 5. Federal Government
Same 6. For-Profit Business or Corporation
Same 7. Consortiums/Collaborations
Same 8. School Districts
Same 9. Institutions of Post-Secondary Education/Training
Same 10. Financial/Banking Institutions
Same 11. Health Service Organizations
Same 12. Statewide Associations or Collaborations
October 2016 Module 2, Section B: CSBG Eligible Entity Capacity Building

Page 27 of 66
FRN #2 – CSBG Annual Report
October 2016 Module 2, Section B: CSBG Eligible Entity Capacity Building

Module 2, Section C: Allocated Resources per CSBG Eligible Entity -
Data Entry Form
►Name of CSBG Eligible Entity: ►Section F, 1.
A. CSBG Eligible Entity Reporting Period – NEW - AUTO "X"
1. July 1 - June 30
2. October 1 - September 30 auto-populated from Module 2, Section A
3. January 1 - December 31
B. Amount of FY 20XX CSBG allocated to reporting entity ►Section F. 2.
C. Federal Resources Allocated (Other than CSBG) From Section F, Part 1, heading/no comparable number.
1. Weatherization (DOE) (include oil overcharge $$ ) ►Section F. 3. 1.
2. Health and Human Services (HHS) ►Section F. 4
a. LIHEAP - Fuel Assistance (include oil overcharge $$ ) ►SAME 2a.
b. LIHEAP - Weatherization (include oil overcharge $$ ) ►SAME 2b.
c. Head Start ►SAME 2c.
d. Early Head Start ►SAME 2d.
e. Older Americans Act ►SAME 2e.
f. Social Services Block Grant (SSBG) ►SAME 2f.
g. Medicare/Medicaid ►SAME 2g.
h. Assets for Independence (AFI) ►SAME 2h.
i. Temporary Assistance for Needy Families (TANF) ►SAME 2i.
j. Child Care Development Block Grant (CCDBG) ►SAME 2j.
k. Community Economic Development (CED) New If applicable 2k.
l. Other HHS Resources ►F.,3 K, i-iv., SAME
i. CFDA #: 2l.i
ii. CFDA #: 2l.ii
iii. CFDA #: 2l.iii
iv. CFDA #: 2l.iv $ -
3. ►Department of Agriculture (USDA) Section F, 5. SAME
a. Special Supplemental Nutrition for Women, Infants, and Children (WIC) 3a.
b. All USDA Non-Food programs (e.g. rural development) 3b.
c. All other USDA Food programs 3c.
4. ►Department of Housing and Urban Development (HUD) Section F, 6. SAME
a. Community Development Block Grant (CDBG) - Federal, State, and Local 4a.
b. Section 8 4b.
c. Section 202 4c.
d. Home Tenant-Based Rental Assistance (HOME TBRA) 4d.
e. HOPE for Homeowners Program (H4H) 4e.
f. Emergency Solutions Grant (ESG) 4f.
g. Continuum of Care (CoC) 4g.
h. All other HUD programs, including homeless programs 4h.
5. ►Department of Labor (DOL) Section F, 7. SAME
a. Workforce Innovation and Opportunity Act (WIOA) *previously WIA 5a.
b. Other DOL Employment and Training programs 5b.
c. All other DOL programs 5c.
6. ►Corporation for National and Community Service (CNCS) programs Section F. 8. SAME 6.
7. ►Federal Emergency Management Agency (FEMA) Section F.9. SAME 7.
8. ►Department of Transportation Section F.10. SAME 8.
9. ►Department of Education Section F. 11. SAME 9.
10. ►Department of Justice Section F. 12 SAME 10.
11. ►Department of Treasury Section F. 13 SAME 11.
12. ►Other Federal Resources Section F. 14. SAME
i. CFDA #: 12.i
ii. CFDA #: 12.ii
iii. CFDA #: 12.iii
iv. CFDA #: 12.iv
13. ►Total Other Federal Resources (auto-calculated) Section F. 14. SAME - 13. $ -
14. ►Total: Non-CSBG Federal Resources Allocated (auto-calculated) Section F. 15 SAME 14 $ -
FRN #2 – CSBG Annual Report Page 28 of 66
October 2016 Module 2, Section C: Allocated Resources per CSBG Eligible Entity

D. ►State Resources Allocated Section F. 16 ALL THE SAME EXCEPT FOR ITEM i
1. a. State appropriated funds used for the same purpose as Federal CSBG funds 1a.
b. State Housing and Homeless programs (include housing tax credits) 1b.
c. State Nutrition programs 1c.
d. State Early Childhood Programs (e.g. Head Start, Day Care) 1d.
e. State Energy programs 1e.
f. State Health programs 1f.
g. State Youth Development programs 1g.
h. State Employment and Training programs 1h.
i. State Head-Start Programs State Senior programs (was j.) 1i.
j. State Transportation programs (was k.) 1j.
k. State Education programs (was l.) 1k.
l. State Community, Rural and Economic Development programs (Was m.) 1l.
m. State Family Development programs (Was n.) 1m.
n. Other State Resources (Was 0.) SAME
i. 1n.i
ii. 1n.ii
iii. 1n.iii
iv. 1n.iv
1n. Total Other State Resources (auto calculated) Section F.16.o. - Auto 1n. $ -
2. Total: State Resources Allocated (auto-calculated) Section F. 17. - Auto 2. $ -
3. If any of these resources were also reported under Item 15 (Federal Resources), please estimate the 3.
amount Section F. 18 - SAME
►E. Local Resources Allocated Section F. 19 SAME
1. a. Amount of unrestricted funds appropriated by local government 1a.
b. Amount of restricted funds appropriated by local government 1b.
c. Value of Contract Services 1c.
d. Value of in-kind goods/services received from local government 1d.
2. Total: Local Resources Allocated (auto-calculated) ►Section F. 20 – SAME 2. $ -
►If any of these resources were also reported under Item 15 or 17 (Federal or State Resources), please
3. estimate the amount. Section F. 21 - SAME 3.
► F. Private Sector Resources Allocated Section F. 22 SAME
1. a. Funds from foundations, corporations, United Way, other nonprofits 1a.
b. Other donated funds 1b.
c. Value of other donated items, food, clothing, furniture, etc. 1c.
d. Value of in-kind services received from businesses 1d.
e. Payments by clients for services 1e.
f. Payments by private entities for goods or services for low income 1f.
clients or communities
2. ►Total: Private Sector Resources Allocated (auto-calculated) 2. $ -
3. ►If any of these resources were also reported under Item 15, 17, or 20 (Federal, State or Local Resources), 3.
please estimate the amount.
►G. Total Non-CSBG Resources Allocated: (Federal, State, Local & Private) (autocalculated) G. $ -
►H. Total Resources in CSBG Eligible Entity (including CSBG) (autocalculated) H. $ -
Note : * All totals are autocalculated
FRN #2 – CSBG Annual Report Page 29 of 66
October 2016 Module 2, Section C: Allocated Resources per CSBG Eligible Entity

Module 3
Community Level
Page 30 of 66

Module 3, Section A: Community Initiative Status Form
Crosswalk: CSBG IS Section D:
Name of CSBG Eligible Entity Reporting:
Use the dropdown menu to select the response where appropriate.
1. ►Initiative Name Indicate program/initiative name here.
2.► Initiative Year 1-7+ years
3.► Problem Identification Narrative
(Provide a narrative on the scope of the problem)
4.►Goal/Agenda Narrative
(Provide a narrative on the goal/agenda)
5.►Issue/CSBG Community Employment; Education and Cognitive Development; Income, Infrastructure,
Domains and Asset Building; Housing; Health and Social/Behavioral Development; or Civic
Engagement and Community Involvement
6.►Ultimate Expected Outcome Community Level National Performance Indicators (NPIs)
(Reference the Community NPIs listed in Section B)
7.►Identified Community
Neighborhood, City, School District, County, [or]Service Area, State, Region, or
Other
8.►Expected Duration Narrative
(Provide the range in years, e.g. 1-3 years)
9.►Partnership Type Independent CAA Initiative, CAA is the core organizer of multi-partner Initiative,
or CAA is one of multiple active investors and partners
10.►Partners Narrative
(Provide a narrative on the key 1-3 partners)
11.►Strategy(ies)
Select from the Community Level Strategies listed in Section C
12.►Progress on
Outcomes/Indicators No Outcomes to Report, Interim Outcomes, Final Outcomes
13.►Impact of Outcomes Narrative
(Provide additional information on the scope of the impact of these outcomes.
e.g. If an initiative created a health clinic, please describe how many individuals
and families are expected to be impacted.)
14.►Outcomes/Indicators Community Level National Performance Indicators (NPIs)
to Report (Reference the Community NPIs listed in Section B)
15.►Final Status Initiative Active, Initiative Ended Early, Initiative Ended as Planned, Completed
Still Delivering Value
16►Lessons Learned
Narrative
October 2016 Module 3, Section A: Community Initiative Status Form Page 33 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Employment Indicators
►Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Employment Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
Counts
1. Number of jobs created to increase opportunities for people with low incomes in the identified community.
of
Change ►2. Number of job opportunities maintained in the identified community. NPI 2.1A
►3. Number of “living wage” jobs created in the identified community*. Parsed from NPI 2.1B, ‘created’ only
►4. Number of “living wage” jobs maintained in the identified community*.Parsed from NPI 2.1B,’ maintained’ only
5. Number of jobs created in the identified community with a benefit package. No NPI equivalent
*When reporting on indicators related to living wage, agencies can provide their own definition or select from national or locally-defined models. Please indicate the living wage definition used in the General Comment box.
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Employment Indicators - Please specify below. No NPI equivalent Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
Counts of
Change
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Employment Indicators No NPI (auto-populated) point used for baseline baseline (% auto calculated)
Rates of equivalent comparisons (Target % auto (% auto
Change (#) calculated) calculated)
►1. Percent decrease of the unemployment rate.
2. Percent decrease of the youth unemployment rate.
3. Percent decrease of the underemployment rate.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Other Other Rates of Change for Employment Indicators No (auto-populated) point used for baseline baseline (% auto calculated)
Rates of NPI equivalent comparisons (Target % auto (% auto
- Please specify below. (#) calculated) calculated)
Change
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Employment Page 34 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Education and Cognitive Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Education and Cognitive Development Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
1. Number of accessible and affordable early childhood or pre-school education assets or resources added to the
identified community.
►2. Number of accredited or licensed affordable child care facilities added in the identified community. Parsed
from NPI 2.1 F – adding a target.
3. Number of new Early Childhood Screenings offered to children (ages 0-5) of families with low-incomes in the
Counts identified community. No NPI equivalent being reported by any agency.
of
Change ►4. Number of accessible and affordable education assets or resources added for school age children in the
identified community. (e.g., academic, enrichment activities, before/after school care, summer programs)NPI
2.1 G – add a target.
►5. Number of accessible and affordable post-secondary education assets or resources added for newly
graduating youth in the identified community. (e.g. college tuition, scholarships, vocational training, etc.) 2.1 I,
adding a target and parsed for post-secondary ed., if available.
►6. Number of accessible and affordable basic or secondary education assets or resources added for adults in the
identified community. (e.g. literacy, ESL, ABE/GED, etc.)NPI 2.1 I – adding a target and parsed for secondary ed. if
available.
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Education and Cognitive Development Indicators - Please specify below. Community (#) Results target accuracy
Counts of (auto-populated) (#) (% auto calculated)
Change
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Education and Cognitive Development Page 35 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Education and Cognitive Development Indicators
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Education and Cognitive Development (auto-populated) point used for baseline baseline (% auto calculated)
Indicators = derived from former Goal comparisons (Target % auto (% auto
6 – NPIs 6.3 (#) calculated) calculated)
►1. Percent increase of children in the identified community who
are kindergarten ready. NPI 6.3 Child D added target
2. Percent increase of children in the identified community at (or
above) the basic reading level. No NPI equivalent
3. Percent increase of children in the identified community at (or
above) the basic math level. No NPI equivalent
Rates of
Change 4. Percent increase in high school (or high school equivalency)
graduation rate in the identified community. No NPI equivalent
5. Percent increase of the rate of youth in the identified
community who attend post-secondary education. No NPI
equivalent
6. Percent increase of the rate of youth in the identified
community who graduate from post-secondary education.
No NPI equivalent
7. Percent increase of adults in the identified community who
attend post-secondary education. No NPI equivalent
8. Percent increase of adults in the identified community who
graduate from post-secondary education. No NPI equivalent
9. Percent increase in the adult literacy rate in the identified
community. No NPI equivalent
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Education and Cognitive Community existing starting (#) change from (#) change from target accuracy
Other Development Indicators - No NPI equivalents (auto populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
Change (#) calculated) calculated)
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Education and Cognitive Development Page 36 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Infrastructure and Asset Building Indicators
►Name of CSBG Eligible Entity Reporting:
Counts of Change for Infrastructure and Asset I.) Identified II.) Target III.) Actual IV.) Performance
Community (#) Results target accuracy
Building Indicators (auto-populated) (#) (% auto calculated)
1. Number of new accessible assets/resources created in the identified community:
►a. Commercial Parsed from NPI 2.2 D adding a
target.
Counts b. Financial
of c. Technological/ Communications (e.g.
Change broadband)
►d. Transportation parsed (if possible) from 2 D,
NPI 2.1 H, add a target.
e. Recreational (e.g. parks, gardens, libraries)
f. Other Public Assets/Physical Improvements
from NPI 2.1 A, B and E
2. Number of existing assets/resources made accessible to the identified community:
a. Commercial Parsed from NPI 2.2 D, adding a
target
b. Financial
c. Technological/ Communications (e.g.
broadband)
►d. Transportation 2.1 H., count, parsed from
NPI 2.1 H. (if possible) from 2 D - adding a target
e. Recreational (e.g. parks, gardens, libraries)
f. Other Public Assets/Physical Improvements
Other Counts of Change for Infrastructure and Asset I.) Identified II.) Target III.) Actual IV.) Performance
Other Community (#) Results target accuracy
Counts of Building Indicators - Please specify below. No (auto populated) (#) (% auto calculated)
NPI equivalents
Change
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Infrastructure and Asset Building Page 37 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Housing Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Housing Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
►1. Number of safe and affordable housing units developed in the identified community (e.g. built or set aside
Counts units for people with low incomes).NPI 2.1 C.
of ►2. Number of safe and affordable housing units maintained and/or improved through WAP or other
Change rehabilitation efforts in the identified community. NPI 2.1 D
3. Number of shelter beds created in the identified community. No NPI equivalents
4. Number of shelter beds maintained in the identified community. No NPI equivalents
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Housing Indicators- Please specify below. Community (#) Results target accuracy
Counts of (auto-populated) (#) (% auto calculated)
Change
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Housing Indicators (auto- point used for baseline baseline (% auto calculated)
populated) comparisons (Target % auto (% auto
(#) calculated) calculated)
1. Percent decrease in the rate of homelessness in the identified
Rates of community. No NPI equivalents
Change 2. Percent decrease in the foreclosure rate in the identified
community. No NPI equivalents
3. Percent increase in the rate of home ownership of people with
low incomes in the identified community. No NPI equivalents
►4. Percent increase of affordable housing in the identified
Community. NPI 2.1 D year to year
5. Percent increase of shelter beds in the identified community. No
NPI equivalents
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Community existing starting (#) change from (#) change from target accuracy
Other Rates of Change for Housing Indicators (auto point used for baseline baseline (% auto calculated)
Rates of - Please specify below. No NPI equivalents populated) comparisons (Target % auto (% auto
Change (#) calculated) calculated)
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Housing Page 39 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Health and Social/Behavioral Indicators
►Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Health and Social/Behavioral Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
Counts ►1. Number of accessible and affordable physical health assets or resources created in the identified community. Parsed from
NPI 2.1 E, adding a target.
of 2. Number of accessible and affordable behavioral and mental health assets or resources created in the identified community. NPI
Change 2.1C, adding a target. Parsed for health (if available)
►3. Number of public safety assets and resources created in the identified community. Parsed from NPI 2.2 C
►4. Number of accessible and affordable healthy food resources created in the identified community. No NPI equivalent
5. Number of activities designed to improve police and community relations within the identified community. No NPI equivalent
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Health and Social/Behavioral Indicators- Please specify below. Community (#) Results target accuracy
Counts of (auto-populated) (#) (% auto calculated)
Change
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing (#) change from (#) change from target accuracy
Rates of Change for Physical Health, Wellbeing, and (auto-populated) starting point baseline baseline (% auto calculated)
Development Indicators No NPI equivalents used for (Target % auto (% auto
comparisons calculated) calculated)
(#)
1. Percent decrease in infant mortality rate in the identified community.
Rates of No NPI equivalent
Change 2. Percent decrease in childhood obesity rate in the identified community.
No NPI equivalent
3. Percent decrease in adult obesity rate in the identified community. No
NPI equivalent
4. Percent increase in child immunization rate in the identified
community. No NPI equivalent
5. Percent decrease in uninsured families in the identified community. No
NPI equivalent
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Health and Social/Behavioral Page 40 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Health and Social/Behavioral Indicators
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing (#) change from (#) change from target accuracy
Rates of Change for Behavioral and Mental health, Emotional (auto-populated) starting point baseline baseline (% auto calculated)
Wellbeing, and Development Indicators – No NPI used for (Target % auto (% auto
equivalents comparisons calculated) calculated)
(#)
1. Percent decrease in the teen pregnancy rate in the identified
community. No NPI equivalent
2. Percent decrease in unplanned pregnancies in the identified
community. No NPI equivalent
Rates of 3. Percent decrease in substance abuse rate in the identified
Change community.(e.g. cigarettes, prescription drugs, narcotics, alcohol). No NPI
equivalent
4. Percent decrease in domestic violence rate in the identified
community. No NPI equivalent
5. Percent decrease in the child abuse rate in the identified community. No
NPI equivalent
6. Percent decrease in the child neglect rate in the identified community.
No NPI equivalent
7. Percent decrease in the elder abuse rate in the identified community.
No NPI equivalent
8. Percent decrease in the elder neglect rate in the identified
community. No NPI equivalent
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing (#) change from (#) change from target accuracy
Rates of Change for Public Safety Indicators- No NPI (auto populated) starting point baseline baseline (% auto calculated)
equivalents used for (Target % auto (% auto
comparisons calculated) calculated)
(#)
Rates of 1. Percent decrease in recidivism rate in the identified community. No NPI
Change equivalent
2. Percent decrease in non-violent crime rate in the identified
community. No NPI equivalent
3. Percent decrease in violent crime rate in the identified community. No
NPI equivalent
4. Percent decrease in teens involved with the juvenile court system in
the identified community. No NPI equivalent
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Health and Social/Behavioral Community existing (#) change from (#) change from target accuracy
Other Indicators - No NPI equivalents (auto populated) starting point baseline baseline (% auto calculated)
Rates of - Please specify below. used for (Target % auto (% auto
Change comparisons calculated) calculated)
(#)
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Community NPIs - Health and Social/Behavioral Page 41 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Civic Engagement and Community Involvement Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Civic Engagement and Community (auto-populated) point used for baseline baseline (% auto calculated)
Involvement Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
►1. Percent increase of donated time to support the CSBG Eligible
Entity's delivery of services and/or implementation of strategies to
Rates of address conditions of poverty in the identified community. NPI 2.3, year
Change to year
►2. Percent increase of donated resources to support the CSBG
Eligible Entity's delivery of services and/or implementation of strategies
to address conditions of poverty in the identified community. Section F,
22, Private funds, year to year, $ amount
►3. Percent increase of people participating in public hearings, policy
forums, community planning, or other advisory boards related to the
CSBG Eligible Entity's delivery of service and/or implementation of
strategies to address conditions of poverty in the identified community.
NPI 3.2 A, D, year to year.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Civic Engagement and Community Community existing starting (#) change from (#) change from target accuracy
Other Involvement Indicators (auto-populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
(#) calculated) calculated)
Change
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Goal 2 Community NPIs - Civic Engagement Community Involvement Page 42 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 3: People with low-incomes are engaged and active in building opportunities in communities.
Civic Engagement and Community Involvement Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Civic Engagement and Community (auto-populated) point used for baseline baseline (% auto calculated)
Involvement Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
Rates of
Change ►1. Percent increase of people with low incomes who support the
CSBG Eligible Entity's delivery of service and/or implementation of
strategies to address conditions of poverty in the identified community.
Number low-income participants, year to year. NPI 3.2, year to year
►2. Percent increase of people with low incomes who acquire
and maintain leadership roles with the CSBG Eligible Entity or
other organizations within the identified community. No NPI
equivalent, but use the number of low-income persons
serving on the board why remained from last year.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Civic Engagement and Community Community existing starting (#) change from (#) change from target accuracy
Other Involvement Indicators -No NPI equivalent (auto-populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
(#) calculated) calculated)
Change
General comments:
FRN #2 –CSBG Annual Report
October 2016 Module 3, Section B: Goal 3 Community NPIs - Civic Engagement Community Involvement Page 43 of 66

Module 3, Section C: Community Strategies List
This will form the dropdown list of choices for Community Strategies – No action on this part
Employment Strategies
Minimum/Living Wage Campaign
Job Creation/Employment Generation
Job Fairs
Earned Income Tax Credit (EITC) Promotion
Commercial Space Development
Employer Education
Employment Policy Changes
Employment Legislative Changes
Other Employment Strategy: (please specify)
Education and Cognitive Development Strategies
Preschool for All Campaign
Charter School Development
After School Enrichment Activities Promotion
Pre K-College/Community College Support
Children’s Trust Fund Creation
Scholarship Creation
Child Tax Credit (CTC) Promotion
Adoption Child Care Quality Rating
Adult Education Establishment
Education and Cognitive Development Policy Changes
Education and Cognitive Development Legislative Changes
Other Education and Cognitive Development Strategy: (please specify)
Infrastructure and Asset Building Strategies
Cultural Asset Creation
Police/Community Relations Campaign
Neighborhood Safety Watch Programs
Anti-Predatory Lending Campaign
Asset Building and Savings Promotion
Develop/Build/Rehab Spaces
Maintain or Host Income Tax Preparation Sites
Community-Wide Data Collection Systems Development
Local 211 or Resource/Referral System Development
Water/Sewer System Development
Community Financial Institution Creation
Infrastructure Planning Coalition
Park or Recreation Creation and Maintenance
Rehabilitation/Weatherization of Housing Stock
Community Center/Community Facility Establishment
Asset Limit Barriers for Benefits Policy Changes
Infrastructure and Asset Building Policy Changes
Infrastructure and Asset Building Legislative Changes
Other Infrastructure and Asset Building Strategy: (please specify)
FRN #2 – CSBG Annual Report
October 2016 Module 3, Section C: Community Strategies List Page 44 of 66

Module 4
Individual and Family Level
Page 47 of 66

Instructional Notes
Module 4 - Individual and Family Level
Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
All Individual and Family NPIs are optional there is a category for "Other Outcome Indicator". CSBG Eligible
Entities will only report an "Other Outcome Indicator" if the current NPIs do not capture the outcomes the CSBG
Eligible Entity is trying to achieve. Sample language is provided in the “Other Outcome Indicator” data entry
section and will be modified by the CSBG Eligible Entity as necessary.
Please see additional notes below:
For All Individual and Family Domains:
Targeting: Targets are set in the Community Action Plan and are identified through the planning phase of the
CAA’s ROMA (Results Oriented Management and Accountability) cycle. The following will be reported for every
indicator:
Column I: Number of Participants Served
Column II: Target (number planned to achieve an outcome in the reporting period)
Column III: Actual Results (actual number of participants who achieved the outcome)
Please note, it is rare that 100% of the people served will achieve the proposed outcome.
Domain Specific Instructions:
Employment, Income and Asset Building, and Housing Domains
Indicators tracking outcomes for 90 or 180 days: CSBG Eligible Entities are only expected to report on
indicators with retention time frames for programs that specifically include follow up. If the CSBG Eligible
Entity does not conduct follow up activities as a part of their programs, outcomes for indicators with retention
time frames will not be reported.
Employment Domain
NPI 5-7: When reporting on indicators related to living wage, CSBG Eligible Entities can provide their own
definition or select from national or locally-defined models. Please identify the living wage definition used in
the General Comments Section.
Income and Asset Building Domain
NPI 1 and 2: CSBG Eligible Entities are only expected to report on basic needs indicators as applicable to the
CSBG Eligible Entity's programs. When reporting on indicators related to basics needs, CSBG Eligible Entities
can provide their own definition or select from national or locally-defined models. Please identify the basic
needs definition used in the General Comments Section.
NPI 8: This indicator requires agencies to keep an unduplicated count of people who report improved financial
well-being based on responses to the CFPB Financial Well Being Scale (found in the link below)
http://www.consumerfinance.gov/reports/financial-well-being-scale/
FRN #2 –CSBG Annual Report
October 2016 Module 4, Instructional Notes Page 48 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Employment Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Employment in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
1. The number of unemployed youth who obtained
employment to gain skills or income.
►2. The number of unemployed adults who
obtained employment (up to a living wage). NPI
1.1 A – parsed from #5 if available
►3. The number of unemployed adults who obtained
and maintained employment for at least 90 days NPI
1.1 B (up to a living wage).Parsed from# 5 if available.
4. The number of unemployed adults who obtained and
maintained employment for at least 180 days
(up to a living wage). New. No NPI equivalent.
5. The number of unemployed adults who obtained
employment (with a living wage or higher). NPI 1.1 A
parsed from # 2 if available.
6. The number of unemployed adults who obtained and
maintained employment for at least 90 days
(with a living wage or higher). NPI 1.1 B parsed from # 3 if
available.
7. The number of unemployed adults who obtained and
maintained employment for at least 180 days
(with a living wage or higher). New. No NPI equivalent.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Employment in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
►8. The number of employed participants in a career-
advancement related program who entered or
transitioned into a position that provided increased
income and/or benefits. NPI 1.1 C.
a. Of the above, the number of employed participants
who Increased income from employment through
wage or salary amount increase. New. No NPI
equivalent.
b. Of the above, the number of employed participants
who increased income from employment through
hours worked increase. New. No NPI equivalent.
c. Of the above, the number of employed participants
who increased benefits related to employment.
New. No NPI equivalent.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Other Employment Outcome Indicator New. No NPI in program(s) (#) [III/ I = IV ] (% auto calculated)
equivalent. calculated)
9. The number of individuals or households
.
Comments:

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Education and Cognitive Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Education and Cognitive Development New. No NPI Served Outcome (III/II = V] (% auto
equivalent for 1-6, 9 and 10. in program(s) (#) [III/ I = IV ] (% calculated)
auto calculated)
1. The number of children (0 to 5) who demonstrated improved
emergent literacy skills. . No NPI equivalent
2. The number of children (0 to 5) who demonstrated skills for
school readiness. . No NPI equivalent
3. The number of children and youth who demonstrated improved
positive approaches toward learning, including improved attention
skills. (auto total). . No NPI equivalent
a. Early Childhood Education (ages 0-5)
b. 1st grade-8th grade
c. 9th grade-12th grade
4. The number of children and youth who are achieving at basic
grade level (academic, social, and other school success skills). (auto
total) . No NPI equivalent
a. Early Childhood Education (ages 0-5)
b. 1st grade-8th grade
c. 9th grade-12th grade
5. The number of parents/caregivers who improved their home
environments.
6. The number of adults who demonstrated improved basic
education.
►7. The number of individuals who obtained a high school diploma
and/or obtained an equivalency certificate or diploma. NPI 1.2 B.,
adding a target
►8. The number of individuals who obtained a recognized
credential, certificate, or degree relating to the achievement of
educational or vocational skills. . NPI 1.2 C., adding a target
9. The number of individuals who obtained an Associate’s degree.
NPI 1.2 C., adding a target. Parsed from #8 if available and adding
a target
10. The number of individuals who obtained a Bachelor’s degree.
NPI 1.2 C., adding a target. Parsed from #8 if available, and adding
a target
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Education and Cognitive Development Outcome Served Outcome (III/II = V] (% auto
Indicator. No NPI equivalent in program(s) (#) [III/ I = IV ] (% calculated)
auto calculated)
11. The number of individuals or households .
Comments:

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Income and Asset Building Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Income and Asset Building
in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
1. The number of individuals who achieved and maintained
capacity to meet basic needs for 90 days. . No NPI
equivalent
2. The number of individuals who achieved and maintained
capacity to meet basic needs for 180 days. . No NPI
equivalent
►3. The number of individuals who opened a savings
account or IDA.
4. The number of individuals who increased their savings. .
No NPI equivalent, but could be parsed from #3
5. ►The number of individuals who used their savings to
purchase an asset. NPIs 1.3 UT I and J.
a. Of the above, the number of individuals who
purchased a home. NPI 1.3 UT I.
6. The number of individuals who improved their credit
scores. No NPI equivalent
7. The number of individuals who increased their net
worth. No NPI equivalent
8. The number of individuals engaged with the Community
Action Agency who report improved financial well-being. No
NPI equivalent, but could derived from SSM data, Income
domain.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Other Income and Asset Building Outcome Indicator No calculated)
in program(s) (#) [III/ I = IV ] (% auto
NPI equivalent
calculated)
9. The number of individuals or households
.
Comments:
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section A: Individual and Family NPIs - Income and Assets Page 52 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Housing Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Housing in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
►1. The number of households experiencing
homelessness who obtained safe temporary shelter. NPI
6.2 E, adding a target.
►2. The number of households who obtained safe and
affordable housing. NPI 1.2 H, and/or 6.4 E, adding a target.
3. The number of households who maintained safe and
affordable housing for 90 days. NPI 1.3 D, and adding
a target.
4. The number of households who maintained safe and
affordable housing for 180 days. No NPI equivalent,
but could be parsed from #2, and adding a target
►5. The number of households who avoided eviction. NPI 6.2
C.
6. The number of households who avoided foreclosure. No
NPI equivalent, but could be parsed from #5
►7. The number of households who experienced
improved health and safety due to improvements within
their home (e.g. reduction or elimination of lead, radon,
carbon dioxide and/or fire hazards or electrical issues,
etc.). NPI 2.1 D
►8. The number of households with improved energy
efficiency and/or energy burden reduction in their homes.
NPI 6.4 H. and or 1.2 K.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Housing Outcome Indicator Served Outcome (III/II = V] (% auto
in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
9. The number of individuals or households
.
Comments:
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section A: Individual and Family NPIs - Housing Page 53 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Health and Social/Behavioral Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Health and Social/Behavioral Development calculated)
in program(s) (#) [III/ I = IV ] (% auto
calculated)
1. The number of individuals who demonstrated increased
nutrition skills (e.g. cooking, shopping, and growing food).
No NPI equivalent
2. The number of individuals who demonstrated improved
physical health and well-being.
►3. The number of individuals who demonstrated
improved mental and behavioral health and well-being.
NPI Y 6.4 E, with added target. Add adults if available.
►4. The number of individuals who improved skills
related to the adult role of parents/ caregivers. NPI 6.3
Adult J.
►5. The number of parents/caregivers who demonstrated
increased sensitivity and responsiveness in their
interactions with their children. . NPI 6.3 Adult K.
►6. The number of seniors (65+) who maintained
an independent living situation. From NPI 6.4 E
with added target.
►7. The number of individuals with disabilities who
maintained an independent living situation. From NPI 6.4 E
with added target
►8. The number of individuals with chronic illness
who maintained an independent living situation.
From NPI 6.4 E with added target
9. The number of individuals with no recidivating event for
six months. No NPI equivalent
a. Youth (ages 14-17)
b. Adults (ages 18+)
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Health and Social/Behavioral Development Served Outcome (III/II = V] (% auto
Outcome Indicator - No NPI equivalent in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
10. The number of individuals or households
.
Comments:
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section A: Individual and Family NPIs - Health and Social/Behavioral Page 54 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Outcomes Across Multiple Domains
Name of CSBG Eligible Entity Reporting:
Add all CAA program participants, add targets/unduplicated – participants achieving any outcome
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Outcomes Across Multiple Domains calculated)
in program(s) (#) [III/ I = IV ] (% auto
calculated)
►1. The number of individuals who achieved one or
more outcomes as identified by the National Performance
Indicators in various domains. No NPI single equivalent..
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Other Outcome Indicator No NPI equivalent in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
2. The number of individuals or households
.
Comments:
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section A: Individual and Family NPIs - Outcomes Across Multiple Domains Page 56 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable
and achieve economic security.
Employment Services – No NPI Equivalent
Name of CSBG Eligible Entity Reporting:
Each agency reports only on the services it provides, indicating the unduplicated number of individuals
served for each service. Individuals may be reported more than once for different services. The arrows
point to existing indicators or known services provided in the network from any source, not just NPIs. The
red arrows are historically reported NPIs. The black arrows are suggested indicators not currently
reported. These would be all individuals served by the CAA in each category, regardless of funding source.
Employment Services Unduplicated Number of
Individuals Served
Skills Training and Opportunities for Experience
►Vocational Training If available
►On-the-Job and other Work Experience If available
►Youth Summer Work Placements If available
Apprenticeship/Internship
Self-Employment Skills Training
Job Readiness Training
Career Counseling
►Workshops If available
Coaching
Job Search
Coaching
Resume Development
Interview Skills Training
►Job Referrals If available.
Job Placements
Pre-employment physicals, background checks, etc.
Post-Employment Supports
Coaching
Interactions with employers
Employment Supplies
►Employment Supplies No equivalent NPI, but report
any employment support supply provided by STCS or
CSBG funds
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Employment Services Page 57 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable
and achieve economic security.
Education and Cognitive Development Services
Name of CSBG Eligible Entity Reporting:
Each agency reports only on the services it provides, indicating the unduplicated number of individuals
served for each service. Individuals may be reported more than once for different services. The arrows
point to existing indicators or known services provided in the network from any source, not just NPIs. The
red arrows are historically reported NPIs. The black arrows are suggested indicators not currently
reported. These would be all individuals served by the CAA in each category, regardless of funding source.
Education and Cognitive Development Services – Unduplicated Number of
No NPI equivalents Individuals Served
Child/Young Adult Education Programs
►Early Head Start NPI 6.3 D
►Head Start NPI 6.3 D
►Other Early-Childhood (0-5 yr. old) Education.
No NPI
K-12 Education
K-12 Support Services
►Financial Literacy Education If available
►Literacy/English Language Education No NPI
College-Readiness Preparation/Support No NPI
Other Post-Secondary Preparation No NPI
Other Post-Secondary Support No NPI
School Supplies
►School Supplies No NPI
Extra-curricular Programs
►Before and After School Activities NPI 2.1 G, and
6.4A
►Summer Youth Recreational Activities No NPI
►Summer Education Programs No NPI
►Behavior Improvement Programs (attitude, self-
esteem, Dress-for-Success, etc.) No NPI
►Mentoring No NPI
►Leadership Training No NPI
Adult Education Programs
►Adult Literacy Classes No NPI
►English Language Classes No NPI
Basic Education Classes No NPI
►High School Equivalency Classes No NPI
Leadership Training No NPI
►Parenting Supports (may be a part of the
early childhood programs identified above)
Applied Technology Classes No NPI
Post-Secondary Education Preparation No NPI
Financial Literacy Education No NPI
Post-Secondary Education Supports
College applications, text books, computers, etc.
No NPI
Financial Aid Assistance
Scholarships No NPI

Home Visits
►Home Visits - No NPI, but provide if available
FRN #2 – CSBG Annual Report
October 2016 Module 4, Module 4, Section B: Education and Cognitive Development Services Page 58 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and
achieve economic security.
Income and Asset Building Services
Name of CSBG Eligible Entity Reporting:
Each agency reports only on the services it provides, indicating the unduplicated number of individuals
served for each service. Individuals may be reported more than once for different services. The arrows
point to existing indicators or known services provided in the network from any source, not just NPIs. The
red arrows are historically reported NPIs. The black arrows are suggested indicators not currently
reported. These would be all individuals served by the CAA in each category, regardless of funding source.
Income and Asset Building Services Unduplicated Number of
Individuals Served
Training and Counseling Services
►Financial Capability Skills Training parsed from NPI 1.3 D
►Financial Coaching/Counseling parsed from NPI 1.3 D
►Financial Management Programs (including budgeting,
credit management, credit repair, credit counseling, etc.)
NPI 1.3 D – all
►First-time Homebuyer Counseling No NPI
►Foreclosure Prevention Counseling No NPI
►Small Business Start-Up and Development Counseling
Sessions/Classes No NPI
►Benefit Coordination and Advocacy
►Child Support Payments NPI 1.3 En. B
►Health Insurance – NPI 1.2 G.
Social Security/SSI Payments
Veteran's Benefits
►TANF Benefits – No NPI – Cash assistance
►SNAP Benefits NPI 1.2 I
►Asset Building
►Saving Accounts/IDAs and other asset building accounts
NPI 1.3 UTE
Other financial products (IRA accounts, MyRA, other
retirement accounts, etc.)
►VITA, EITC, or Other Tax Preparation programs NPI 1.3 A
Loans And Grants
Micro-loans
Business incubator/business development loans
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Income and Asset Building Services Page 59 of 66

Module 4, Section B: Individual and Family Services - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve
economic security.
Housing Services
Name of CSBG Eligible Entity Reporting:
Each agency reports only on the services it provides, indicating the unduplicated number of individuals
served for each service. Individuals may be reported more than once for different services. The arrows
point to existing indicators or known services provided in the network from any source, not just NPIs. The
red arrows are historically reported NPIs. The black arrows are suggested indicators not currently
reported. These would be all individuals served by the CAA in each category, regardless of funding source.
Housing Services Unduplicated Number of
Individuals Served
►Housing Payment Assistance
►Financial Capability Skill Training NPI 1.3 D, Number of participants
►Financial Coaching/Counseling NPI 1.3 D, parse if distinct from Number of participants
above
►Rent Payments (includes Emergency Rent Payments) NPI 6.2 C, All rental assistance payment/all
E programs/funding sources
►Deposit Payments No NPI – Could be parsed from 6.2 above All rental deposit
All mortgage payments
►Mortgage Payments (includes Emergency Mortgage
Payments) No NPI, but should find it in CMT data, and other mtg
pmts.
Eviction Prevention Services
Eviction Counseling No NPI If available
Landlord/Tenant Mediations No NPI If available
Landlord/Tenant Rights Education No NPI If available
►Utility Payment Assistance
►Utility Payments (LIHEAP-includes Emergency Utility Total LIHEAP payments, and other Utility
Payments) NPI 6.2 B and/or 1.2 J. Assistance including deposits and
arrears.
►Utility Deposits (for 2018, if available – report for 2019) Of the above
►Utility Arrears Payments (if available) Of the above
Level Billing Assistance (optional)
Housing Placement/Rapid Re-housing
All temporary housing
►Temporary Housing Placement (includes Emergency Shelters)
NPI 6.2 E
Transitional Housing Placements If available
►Permanent Housing Placements NPI 1.2 H
Rental Counseling If available
Housing Maintenance & Improvements
►Home Repairs (e.g. structural, appliance, heating systems. etc.) If available
(Including Emergency Home Repairs) No NPI
►Weatherization Services
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Housing Services Page 60 of 66

►Independent-living Home Improvements (e.g. ramps, tub and
shower grab bars, handicap accessible modifications, etc.) Parsed
from NPI 2.1 D, if available.
►Healthy Homes Services (e.g. reduction or elimination of
lead, radon, carbon dioxide and/or fire hazards or electrical
issues, etc.) Parsed from NPI 2.1 D, if available.
►Energy Efficiency Improvements (e.g. insulation, air
sealing, furnace repair, etc.) NPI 2.1 D
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Housing Services Page 60 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and
achieve economic security.
Health and Social/Behavioral Development
Name of CSBG Eligible Entity Reporting:
Each agency reports only on the services it provides, indicating the unduplicated number of individuals
served for each service. Individuals may be reported more than once for different services. The arrows
point to existing indicators or known services provided in the network from any source, not just NPIs. The
red arrows are historically reported NPIs. The black arrows are suggested indicators not currently
reported. These would be all individuals served by the CAA in each category, regardless of funding source.
No NPI Equivalents
Health and Social/Behavioral Development Services - No Unduplicated Number of
NPIs Individuals Served
Health Services, Screening and Assessments
Immunizations
Physicals
Developmental Delay Screening
Vision Screening
Prescription Payments
Doctor Visit Payments
Maternal/Child Health
Nursing Care Sessions
In-Home Affordable Seniors/Disabled Care Sessions
(Nursing, Chores, Personal Care Services)
Health Insurance Options Counseling
Reproductive Health Services
Coaching Sessions
Family Planning Classes
Contraceptives
STI/HIV Prevention Counseling Sessions
STI/HIV Screenings
Wellness Education
Wellness Classes (stress reduction, medication management,
mindfulness, etc.)
Exercise/Fitness
Mental/Behavioral Health
Detoxification Sessions
Substance Abuse Screenings
Substance Abuse Counseling
Mental Health Assessments
Mental Health Counseling
Crisis Response/Call-In Responses
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Health and Social/Behavioral Development Services Page 61 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and
achieve economic security.
Health and Social/Behavioral Development
Name of CSBG Eligible Entity Reporting:
Domestic Violence Programs
Support Groups
Substance Abuse Support Group Meetings
Domestic Violence Support Group Meetings
Mental Health Support Group Meeting
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Health and Social/Behavioral Development Services Page 62 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and
achieve economic security.
Health and Social/Behavioral Development
Name of CSBG Eligible Entity Reporting:
Each agency reports only on the services it provides, indicating the unduplicated number of individuals
served for each service. Individuals may be reported more than once for different services. The arrows
point to existing indicators or known services provided in the network from any source, not just NPIs. The
red arrows are historically reported NPIs. The black arrows are suggested indicators not currently
reported. These would be all individuals served by the CAA in each category, regardless of funding source.
Health and Social/Behavioral Development Services (Cont'd.) Unduplicated Number of
Individuals Served
Dental Services, Screenings and Exams
Adult Dental Screening/Exams
Adult Dental Services (including Emergency Dental Procedures)
Child Dental Screenings/Exams
Child Dental Services (including Emergency Dental Procedures)
►Nutrition and Food/Meals
►Skills Classes (Gardening, Cooking, Nutrition) no equivalent NPI
►Community Gardening Activities - no equivalent NPI
►Incentives (e.g. gift card for food preparation, rewards for
participation, etc.) no equivalent NPI
►Prepared Meals – Agency wide - # of participants no equivalent
NPI
►Food Distribution (Food Bags/Boxes, Food Share Program, Bags
of Groceries) Similar to NPI 6.5 A & B, but INDIVIDUALS served,
not UNITS distributed.
►Family Skills Development
Family Mentoring Sessions
Life Skills Coaching Sessions
Parenting Classes
►Emergency Hygiene Assistance
Kits/boxes
Hygiene Facility Utilizations (e.g. showers, toilets, sinks)
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Health and Social/Behavioral Development Services Page 63 of 66

Module 4, Section B: Individual and Family Services - Data Entry
Form
Goal 1: Individuals and Families with low-incomes are stable and
achieve economic security.
Services Supporting Multiple Domains
Name of CSBG Eligible Entity Reporting:
Each agency reports only on the services it provides, indicating the unduplicated number of individuals
served for each service. Individuals may be reported more than once for different services, but only once
in a given service. The arrows point to existing indicators or known services provided in the network from
any source, not just NPIs. The red arrows are historically reported NPIs. The black arrows are suggested
indicators not currently reported. These would be all individuals served by the CAA in each category,
regardless of funding source.
Services Supporting Multiple Domains
Unduplicated Number of
Individuals Served
►Case Management
Case Management – Total case managed individuals – (not one time)
Agency wide
►Eligibility Determinations
Eligibility Determinations For all programs - total individual applications
(approved and denied) – Agency wide
►Referrals
Referrals – All referrals and calls – NPI 6.4 E, (calls), and physical
referrals. Agency wide
►Transportation Services
Transportation Services (e.g. bus passes, bus transport, support for Include any STCS or CSBG
auto purchase or repair; including emergency services) NPI 1.2 f. and or other source services
6.2 D, if auto related, and 6.2 I. and 6.5 D that involve a car repair as
well as other
transportation services,
emergency and non-
emergency
Childcare If available
Child Care subsidies
Child Care payments
►Eldercare
Day Centers Senior Centers, congregant meal clients if available
Identification Documents
Birth Certificate
Social Security Card
Driver's License
Re-Entry Services
Criminal Record Expungements
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Services Supporting Multiple Domains Page 63 of 66

Module 4, Section B: Individual and Family Services - Data Entry
Form
Goal 1: Individuals and Families with low-incomes are stable and
achieve economic security.
Services Supporting Multiple Domains
Name of CSBG Eligible Entity Reporting:
Immigration Support Services
Immigration Support Services (relocation, food, clothing)
Legal Assistance (includes emergency legal assistance)
Legal Assistance
►Emergency Clothing Assistance
Emergency Clothing Assistance Individuals Similar to NPI 6.5 C, but
individuals
Mediation/Customer Advocacy Interventions (debt forgiveness, negotiations or issues with
landlords, coordinating with other services or government)
Mediation/Customer Advocacy Interventions
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Services Supporting Multiple Domains Page 63 of 66

Module 4, Section B: Individual and Family Services - Data Entry
Form
Goal 1: Individuals and Families with low-incomes are stable and
achieve economic security.
Civic Engagement and Community Involvement
Name of CSBG Eligible Entity Reporting:
No NPI equivalent
Each agency reports only on the services it provides, indicating the unduplicated number of individuals
served for each service. Individuals may be reported more than once for different services, but only once
within in a given service. The arrows point to existing indicators or known services provided in the
network from any source, not just NPIs. The red arrows are historically reported NPIs. The black arrows
are suggested indicators not currently reported. These would be all individuals served by the CAA in each
category, regardless of funding source.
Civic Engagement and Community Involvement Services- No Unduplicated Number of
Equivalent NPIs Individuals Served
Voter Education and Access
►Leadership Training
►Tri-partite Board Membership (for 2018)
Citizenship Classes
Getting Ahead Classes
►Volunteer Training
FRN #2 – CSBG Annual Report
October 2016 Module 4, Section B: Civic Engagement and Community Involvement Services Page 64 of 66

Module 4, Section C: All Characteristics Report - Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.
Name of CSBG Eligible Entity Reporting:
A. Total unduplicated number of all INDIVIDUALS about whom one or more characteristics were obtained: Sec G 3. Same
B. Total unduplicated number of all HOUSEHOLDS about whom one or more characteristics were obtained: Sec G 5. Same
Items 2a., 2b,. 4 and 6 are removed, see bottom of section. Commented [GDL1]:
Total Counts: Counts of Individuals
C. INDIVIDUAL LEVEL CHARACTERISTICS and Families for whom no characteristics were collected are
1. ►Gender Sec G. 7.- SAME/W/ADDS Number of Individuals 6. ►Ethnicity/Race Sec G. 9. - SAME Number of Individuals in the box at the bottom of this section. They can use that
a. Male Same I. Ethnicity number to determine the unknowns in each category. This
b. Female same a. Hispanic, Latino or Spanish Origins Same
b. Not Hispanic, Latino or Spanish Origins Same section will be a challenging data point, as it must be
c. Other - ADDED new c. Unknown/not reported ADDED New collected at intake. It will involve changes to forms and
d. Unknown/not reported ADDED new TOTAL (auto calculated) 0 procedures.
2. ►Age Sec G. 8 SAME Number of Individuals II. Race
a. 0-5 Same a. American Indian or Alaska Native Same
b. 6-13 Same b. Asian Same
c. 14-17 Same c. Black or African American Same
d. 18-24 Same d. Native Hawaiian and Other Pacific Islander Same
e. 25-44 Same e. White Same
f. 45-54 Same f. Other Same
g. 55-59 Same g. Multi-race (two or more of the above) Same
h. 60-64 Same h. Unknown/not reported - ADDED New
i. 65-74 Same TOTAL (auto calculated) 0
j. 75+ Same
k. Unknown/not reported New 7. Military Status - NEW Number of Individuals
TOTAL (auto calculated) 0 a. Veteran New
b. Active Military New
3. ►Education Levels – Sec G 10 SAME/W/ADDS Number of Individuals c. Unknown/not reported New
TOTAL (auto calculated)
[ages 14-24] [ages 25+] 0
a. Grades 0-8 Same
b. Grades 9-12/Non-Graduate Same 8. Work Status (Individuals 18+) NEW Number of Individuals
c. High School Graduate/ Equivalency Diploma Same a. Employed Full-Time New
d. 12 grade + Some Post-Secondary Same b. Employed Part-Time New
e. 2 or 4 years College Graduate Same c. Migrant Seasonal Farm Worker New
f. Graduate of other post-secondary school Same d. Unemployed (Short-Term, 6 months or less) New
g. Unknown/not reported Same e. Unemployed (Long-Term, more than 6 months) New
TOTAL (auto calculated) New f. Unemployed (Not in Labor Force) New
g. Retired New
4. Disconnected Youth NEW Number of Individuals h. Unknown/not reported New
a. Youth ages 14-24 who are neither working or in school TOTAL (auto calculated)
5.► Health – Sec G.11. SAME W/ADDS Number of Individuals
Yes No Unknown
a. Disabling Condition Same
Yes No Unknown
b. Health Insurance* Same
*If an individual reported that they had Health Insurance please identify the source of health
Insurance below.
Health Insurance Sources NEW New
i. Medicaid New
ii. Medicare New
iii. State Children’s Health Insurance Program New
iv. State Health Insurance for Adults New
v. Military Health Care New
vi. Direct-Purchase New
vii. Employment Based New
viii. Unknown/not reported New
TOTAL (auto calculated) 0
FRN #2 – CSBG Annual Report Page 65 of 66
October 2016 Module 4, Section C: All Characteristics Report

Module 4, Section C: All Characteristics Report - Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.
Name of CSBG Eligible Entity Reporting:
D. HOUSEHOLD LEVEL CHARACTERISTICS - Section G -
9. Household Type Sec G 12 W/ADDS Number of Households 13. ►Sources of Household Income Sec G 13/ adds Number of Households
a. Single Person SAME a. Income from Employment Only SAME
b. Two Adults NO Children NEW b. Income from Employment and Other Income Source SAME
c. Single Parent Female SAME c. Income from Employment, Other Income Source, NEW
d. Single Parent Male SAME and Non-Cash Benefits
e. Two Parent Household SAME d. Income from Employment and Non-Cash Benefits NEW
f. Non-related Adults with Children NEW e. Other Income Source Only NEW
g. Multigenerational Household NEW f. Other Income Source and Non-Cash Benefits
h. Other NEW g. No Income
i. Unknown/not reported NEW h. Non-Cash Benefits Only
TOTAL (auto calculated) 0 i. Unknown/not reported
Order changed. TOTAL (auto calculated) 0
10. ►Household Size – SEC G 13 Number of Households Below, please report the types of Other income and/or non-cash benefits received by
a. Single Person SAME the households who reported sources other than employment
14. Other Income Source Sec G. 14 Mostly NEW Number of Households
b. Two SAME
c. Three SAME a. TANF Same
d. Four SAME b. Supplemental Security Income (SSI) Same
e. Five SAME c. Social Security Disability Income (SSDI) Same
f. Six or more CHANGED d. VA Service-Connected Disability Compensation New
g. Unknown/not reported NEW e. VA Non-Service Connected Disability Pension New
TOTAL (auto calculated) 0 f. Private Disability Insurance New
g, Seven, and h., Eight or more, g. Worker’s Compensation New
eliminated.
h. Retirement Income from Social Security Same
11. ►Housing Sec G. 16 Number of Households i. Pension Same
a. Own SAME j. Child Support New
b. Rent SAME k. Alimony or other Spousal Support New
c. Other permanent housing NEW l. Unemployment Insurance Same
d. Homeless SAME m. EITC New
e. Other NEW n. Other New
f. Unknown/not reported 0 o. Unknown/not reported New
TOTAL (auto calculated)
15. Non-Cash Benefits NEW Number of Households
12.► Level of Household Income Number of Households a. SNAP New
(% of HHS Guideline) Same b. WIC New
a. Up to 50% Same c. LIHEAP New
b. 51% to 75% Same d. Housing Choice Voucher New
c. 76% to 100% Same e. Public Housing New
d. 101% to 125% Same f. Permanent Supportive Housing New
e. 126% to 150% Same g. HUD-VASH New
f. 151% to 175% Same h. Childcare Voucher New
g. 176% to 200% New i. Affordable Care Act Subsidy New
h. 201% to 250% New j. Other New
i. 250% and over New k. Unknown/not reported
j. Unknown/not reported 0
TOTAL (auto calculated)
Number of Individuals Not Included in the Totals Above (due to data collection system integration barriers)
Please list the unduplicated number of INDIVIDUALS served in each program*:
Program Name Number of Individuals
Section G 4
Number of Households Not Included in the Totals Above (due to data collection system integration barriers)
Please list the unduplicated number of HOUSEHOLDS served in each program*:
Program Name Number of Households
Sectjon G 6
FRN #2 – CSBG Annual Report Page 66 of 66
October 2016 Module 4, Section C: All Characteristics Report

High-Level Crosswalk
CSBG Annual Report – CSBG IS Survey
FRN#2 30-Day Comment Period
Module 1 - State Administration CSBG IS Survey
Section A: CSBG Lead Agency, CSBG Authorized Official,
Section C. General Information on State CSBG office
CSBG Point of Contact
Section B: Statewide Goals and Accomplishments Section D. Accomplishments and Coordination of
Funds
Section C: CSBG Eligible Entity Update Section B. General Information on Local CSBG
Agencies
Section D: Organizational Standards for Eligible
n/a
Entities
Section E: State Use of Funds Section A. State Use of CSBG Funds
Section B. General Information on Local CSBG
Agencies
Section F: State Training and Technical Assistance T/TA Survey
Section B. General Information on Local CSBG
Agencies
Section G: State Linkages and Communication n/a
Section H: Monitoring, Corrective Action, and Fiscal
n/a
Controls
Section I: Results Oriented Management and
Accountability (ROMA) n/a
Module 2 – CSBG Eligible Entity
CSBG IS Survey
Expenditures, Capacity, and Resources
Section A: Local Agency CSBG Expenditures
Section E. CSBG Expenditures by Service Category
Section B: Local Agency Capacity Building National Performance Indicator 2.3 – Community
Engagement
National Performance Indicator 3.1 - Community
Empowerment through Maximum Feasible
Participation
National Performance Indicator 4.1 - Expanding
Opportunities through Community-Wide Partnerships
National Performance Indicator 5.1 – Expanding
Opportunities through Community-Wide Partnerships
Section C: Local Agency Resources Administered by Section F. Resources Administered and Generated by
the CSBG Eligible Entity the CSBG Network
11/2/2016

SFY-18-K1 Attachment #3
High-Level Crosswalk
CSBG Annual Report – CSBG IS Survey
FRN#2 30-Day Comment Period
Module 3 – Community Level CSBG IS Survey
Section A: Community Initiative Status Form National Performance Indicator 4.1 - Expanding
Opportunities through Community-Wide Partnerships
Section B: Community National Performance National Performance Indicator 2.1 – Community
Indicators (NPIs) Improvement and Revitalization
National Performance Indicator 2.2 – Community
Quality of Life and Assets
National Performance Indicator 2.3 – Community
Engagement
National Performance Indicator 3.2 – Community
Empowerment through Maximum Feasible
Participation
Section C: Community Strategies National Performance Indicator 2.1 – Community
Improvement and Revitalization
Module 4 - Individual and Family Level CSBG IS Survey
Section A: Individual and Family National Performance National Performance Indicator 1.1 – Employment
Indicators (NPI)
National Performance Indicator 1.2 – Employment
Supports
National Performance Indicator 1.3 – Employment
Asset Enhancement and Utilization
National Performance Indicator 6.1 – Independent
Living
National Performance Indicator 6.3 – Child and Family
Development
Section B: Individual and Family Services National Performance Indicator 1.2 – Employment
Supports
National Performance Indicator 6.2 – Emergency
Assistance
National Performance Indicator 6.4 – Family Supports
National Performance Indicator 6.5 – Services Counts
Section C: All Characteristics Report
Section G. Program Participant Characteristics
11/2/2016

OMB Control No: 0970-0492
SFY-18-K1 Attachment #4
Expiration date: 01/31/2020
Community Services Block
Grant (CSBG) Annual Report

CSBG Annual Report Table of Contents
Module 1 - State Administration………………………………………………………………………………………………………………1
Section A: CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact////////////.2
Section B: Statewide Goals and Accomplishments...////////////////////////////4
Section C: CSBG Eligible Entity Update..................................................................................................6
Section D: Organizational Standards for Eligible Entities......................................................................7
Section E: State Use of Funds..............................................................................................................10
Section F: State Training and Technical Assistance.............................................................................15
Section G: State Linkages and Communication.....................................................................................17
Section H: Monitoring, Corrective Action, and Fiscal Controls...........................................................20
Section I: Results Oriented Management and Accountability (ROMA) System..................................22
Module 2 – CSBG Eligible Entity Expenditures, Capacity, and Resources...................................................24
Module 2 Instructional Notes////////////////////////////////////////25
Section A: Local Agency CSBG Expenditures.......................................................................................26
Section B: Local Agency Capacity Building..........................................................................................27
Section C: Local Agency Resources Ad ministered by the CSBG Eligible Entity....................................28
Module 3 – Community Level…………………………………………………………………………………………………………………30
Module 3 Instructional Notes////////////////////////////////////////31
Section A: Community Initiative Status Form.....................................................................................33
Section B: Community National Performance Indicators (NPIs)...........................................................34
Section C: Community Strategies////.............................................................................................44
Module 4 - Individual and Family Level…………………………………………………………………………………………………..47
Module 4 Instructional Notes////////////////////////////////////////48
Section A: Individual and Family National Performance Indicators (NPIs)///////////////.50
Section B: Individual and Family Services............................................................................................57
Section C: All Characteristics Report////////////////////////////////////.65

Module 1
State Administration
Page 1 of 66

Community Services Block Grant (CSBG)
Annual Report – State Administration Module
Note: The reporting timeframes for all information in the administrative module is based on the
Federal Fiscal Year, which runs from October 1 of a given calendar year until September 30 of the
following calendar year. When completing the annual report, respondents will first indicate the
Federal Fiscal Year for which the state is submitting data. The Online Data Collection (OLDC) system
will then auto-populate the administrative module with information from the appropriate year (year 1
or year 2) in the accepted CSBG State Plan. States will be able to update information in these sections,
as necessary.
SECTION A
CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact
A.1. Confirm and update the following information in relation to the lead agency designated to
administer the CSBG in the State, as required by Section 676(a) of the CSBG Act.
A.1a. Lead agency
Formerly State [This section will auto-populate using information provided in the CSBG State Plan. The
Contact State should review all items and may update to note any changes that have taken place
Information - during the year. Any updates or changes will be noted in quality assurance reviews and
CSBG IS Access may require brief explanation prior to acceptance of the annual report.]
Database
A.1b. Cabinet or administrative department of this lead agency
[Auto-populated from the CSBG State Plan with option to update where applicable]
CSBG IS, Section
C, Question 1 Community Services Department
Human Services Department
Social Services Department
Governor’s Office
Community Affairs Department
CSBG IS, Other, describe:
Section C,
Question 2 A.1c. Division, bureau, or office of the CSBG authorized official [Narrative, 2500 Characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1d. Authorized official of the lead agency [Narrative, 2500 C haracters]
CSBG State Plan [Auto-populated from the CSBG State Plan with option to update where applicable]
Instructional note: The authorized official could be the director, secretary,
commissioner etc. as assigned in the designation letter (attached under item 1.3). The
authorized official is the person indicated as authorized representative on the SF-
424M.
Module 1 Page 2 of 66
State Administration

A.1e. Street address [Narrative, 2500 Characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1f. City [Narrative, 2500 Characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1g. State [Narrative, 2500 Characters]
[Auto-populated from the CSBG State Plan]
A.1h. Zip code [Narrative 10 Characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
CSBG State Plan
Information A.1i. Telephone number and extension [Narrative, 10 – 15 characters including an option for
5 digit extension]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1j. Fax number [Narrative, 10 characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1k. Email address [Narrative, 50 characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.1l. Lead agency website [Narrative, 200 characters]
[Auto-populated from the CSBG State Plan with option to update where applicable]
A.2. Please check additional programs administered by the State CSBG Lead Agency during the
reporting year (FFY).
CSBG IS, Section Weatherization Assistance Program (WAP)
C, Question 3 Low Income Home Energy Assistance Program ( LIHEAP)
U.S. Department of Agriculture Programs (Specify __________________)
U.S. Department of Housing and Urban Development (HUD) Programs (Specify
_________________)
Other, describe: If yes, please list below:
Module 1 Page 3 of 66
State Administration

SECTION B
Statewide Goals and Accomplishments
B.1. Progress on State Plan Goals: Describe progress in meeting the State’s CSBG-specific goals for
State administration of CSBG as described in the CSBG State Plan.
Goals: [Actual Goals from the CSBG State Plan will be auto-populated from the accepted CSBG
State plan]
All Goals Accomplished: [Narrative, 2500 characters]
Goals Partially Accomplished – describe progress: [Narrative, 2500 characters]
Not Accomplished – explain [Narrative, 2500 characters]
Note: This information is associated with State Accountability Measure 1Sa(i) and will be used
in assessing overall progress in meeting State goals.
B.2. CSBG Eligible Entity Overall Satisfaction Targets: In the table below, provide the State’s most
recent target for CSBG Eligible Entity Overall Satisfaction during the performance period (FFY).
Prior Year Target Most Recent American Future Target
Customer Satisfaction Index
NEW: Follow- Survey Result
up to content in ___. [Numerical, 3 digits] ___. [Numerical, 3 digits] ___. [Numerical, 3 digits]
CSBG State
Plan This cell should be left blank in This cell should include the most Note: OCS issued
the first year of submission of recent result of the ACSI survey. Information
this new annual report format. OCS plans to issue ACSI surveys Memorandum 150
on a bi-annual basis. providing guidance on
establishing targets based
on ACSI results.
Instructional Note: Because the CSBG State Plan may cover two fiscal years, annual updates
related to CSBG Eligible Entity satisfaction should be provided in this annual report. The State’s
target score will indicate improvement or maintenance of the States’ Overall Satisfaction score
from the most recent American Customer Survey Index (ACSI) survey of the State’s CSBG
Eligible Entities. States that did not receive ACSI scores (i.e. States with only a single CSBG
Eligible Entity) should not complete question B.2, but should provide narrative descriptions of
other sources of customer feedback and the State’s response to that feedback in question B.3.
For more information on the ACSI and establishment of targets, see CSBG Information
Memorandum #150 Use of the American Customer Satisfaction Index (ACSI) to Improve Network
Effectiveness.
B.3. CSBG Eligible Entity Feedback and Involvement: How has the State considered feedback from
CSBG Eligible Entities, OCS, public hearings, and other sources, and/or customer satisfaction
surveys such as the American Customer Satisfaction Index (ACSI)? What actions have been
taken as a result of this feedback?
[Narrative - 2500 Characters]
Module 1 Page 4 of 66
State Administration

B.4. State Management Accomplishment: Describe what you consider to be the top management
accomplishment achieved by your State CSBG office during the reporting year (FFY). Provide
CSBG IS, examples of how administrative or leadership actions led to improvements in efficiency,
Section D, accountability, or quality of services and strategies.
Question 2a [Narrative – 2500 Characters]
B.5. CSBG Eligible Entity Management Accomplishments: Describe three notable management
accomplishments achieved by CSBG Eligible Entities in your state during the reporting year
CSBG IS, (FFY). Describe how responsible, informed leadership and effective, efficient processes led to
Section D, high-quality, accessible, and well-managed services and strategies.
Question 2b
[Narrative – 2500 Characters]
B.6. Innovative Solutions Highlights: Provide at least three examples of ways in which a CSBG
Eligible Entity addressed a cause or condition of poverty in the community using an innovative
or creative approach. Provide the agency name, local partners involved, outcomes, and specific
CSBG IS, information on how CSBG funds were used to support implementation.
Section D, [Narrative – 2500 Characters]
Questions 3a
Module 1 Page 5 of 66
State Administration

SECTION C
CSBG Eligible Entity Update
C.1. CSBG Eligible Entities: The table below includes a list of CSBG Eligible Entities in the State as
described in the CSBG State Plan for this reporting year (FFY). Please review and note any
changes or updates in this information. This table should include every CSBG Eligible Entity to
which the State allocated 90 percent of CSBG funds during the reporting period (FFY). The table
C.1 combines should not include entities that only receive remainder/discretionary funds from the State or
CSBG IS
tribes/tribal organizations that receive direct funding from OCS under Section 677 of the CSBG
Access
Act.)
Database,
Section B, the 4.Geographical
Eligible Entity 1.CSBG Eligible 2.Public or 3.Type of Entity Area Served by 5.Brief Description
list, and Entity Nonprofit (choose all that apply) county (Provide of “Other”
Section B, all counties)
Questions 1 Auto-populated Auto-populated Auto-populated Auto-populated Auto-populated
[Narrative, 2500 [Select Public or • Community Action [Narrative, 2500 [Narrative, 2500
and 4 characters] Nonprofit] Agency characters] characters]
• Limited Purpose Agency
This form will • Local Government If “Other” is
auto-populate Agency selected in column
from the State • Migrant or Seasonal 3, provide further
Plan Farmworker detail here
Organization
• Tribe or Tribal
Organization
• Other (describe in
column 5)
ADD A ROW function Note: rows may be added for each CSBG Eligible Entity funded by the State
C.2. Total number of CSBG Eligible Entities: __##__ [This will automatically update based on chart
in C.1]
CSBG
IS, C.3. Changes to CSBG Eligible Entities List: Did the list of CSBG Eligible Entities under item C.1
Section change during the reporting period (FFY)? If yes, briefly describe the changes. Yes No
B,
Questio [If yes is selected – Narrative, 2500 characters]
1
Instructional Note: Limited Purpose Agency refers to a CSBG Eligible Entity that was
designated as a limited purpose agency under Title II of the Economic Opportunity Act of
1964 for the fiscal year 1981, that served the general purposes of a community action agency
under Title II of the Economic Opportunity Act; 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 has not lost its designation as a CSBG Eligible Entity under the CSBG Act.
Instructional Note: 90 percent funds are the funds a State provides to CSBG 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.
Module 1 Page 6 of 66
State Administration

NEW: All of Section D and it will populate with the information entered into the State Plan
SECTION D
Organizational Standards for CSBG Eligible Entities
Note: Reference CSBG Information Memorandum #138 State Establishment of Organizational
Standards for CSBG Eligible Entities
D.1. Assessment of Organizational Standards: The CSBG State Plan indicated that the State would
use the following organizational standards for its oversight of the CSBG:
[One of the options below will be auto-populated from the CSBG State Plan based on the
items checked in question 6.1 of the CSBG State Plan]
• CSBG Organizational Standards Center of Excellence (COE) organizational
standards (as described in IM 138) or a modified version of these standards.
• An alternative set of organizational standards as outlined in supporting
documentation to the CSBG State plan.
D.1a.How did the State assess CSBG eligible entities against organizational standards, as
described in IM 138?
[The checkbox below will be auto-populated from the CSBG State Plan with the option for the
State to update information based on its actual implemented assessment process]
Peer-to-peer review (with validation by the State or State-authorized third party)
Self-assessment (with validation by the State or State-authorized third party)
Self-assessment/peer review with State risk analysis
State-authorized third party validation
Regular, on-site CSBG monitoring
Other
D.1b. Describe the assessment process as implemented by the State. Please describe any
changes in the assessment process that occurred since the time of the State plan submission.
Please note that with the exception of regular on-site CSBG monitoring, all assessment options
above may include either on-site or desk review (or a combination). The specific State process
should be described in the narrative. [Narrative, 2500 characters]
Module 1 Page 7 of 66
State Administration

D.2. Organizational Standards Performance: In the table below, please provide the percentage of
CSBG Eligible Entities that met all State-adopted organizational standards in the reporting
period (FFY). The target set in the CSBG State Plan is provided in the left-hand column. For
more information on the CSBG Organizational Standards, see CSBG Information Memorandum
#138.
Target vs. Actual Performance on the Organizational Standards
Fiscal Year State CSBG Number of Number that Met Actual Percentage
Plan Target Entities Assessed All (100%) of Meeting All (100%) of
State Standards State Standards
Auto- [Auto-populated [Insert a number [Insert a number [Auto-calculated]
populated target from question between 0 – 99] between 0 – 99]
6.6. of the State
CSBG plan].
Progress Indicators
Indicate the number of entities that met the following percentages of Organizational Standards.
Number of Number that Met Actual Percentage
Entities Assessed between 90% and
99% of State
Standards
[Insert a number [Insert a number [Auto-calculated]
between 0 – 99] between 0 – 99]
Note – While the State targets the Number of Number that met Actual Percentage
percent of CSBG Eligible Entities to Entities Assessed between 80% and
meet 100% of the Organizational 89% of State
Standards, targets are not set in the Standards
State Plan for 90%, 80%, 70%, and 60% [Insert a number [Insert a number [Auto-calculated]
progress indicators. between 0 – 99] between 0 – 99]
Number of Number that met Actual Percentage
Entities Assessed between 70% and
79% of State
Standards
[Insert a number [Insert a number [Auto-calculated]
between 0 – 99] between 0 – 99]
Note: This information is associated with State Accountability Measures 6Sa.
D.2a. In the space below, please identify the challenges and factors contributing to the
difference between the target and actual results provided in the top row of Table D.2 (above).
[Narrative, 2500 characters]
Module 1 Page 8 of 66
State Administration

D.2b. Percentage Meeting Organizational Standards by Category. In the table below, provide
the number of eligible entities that met each category of the Organizational Standards. The
percentage that met all standards in each category will be automatically calculated and totaled
in the bottom row.
Percentage Meeting Organizational Standards by Category
Number that
Number of Entities Met All Actual
Category
Assessed Standards in Percentage
Category
1. Consumer Input and [Insert a number [Insert a number
[Auto-calculated]
Involvement between 0 – 99] between 0 – 99]
2. Community Engagement [Insert a number [Insert a number
[Auto-calculated]
between 0 – 99] between 0 – 99]
3. Community Assessment [Insert a number [Insert a number
[Auto-calculated]
between 0 – 99] between 0 – 99]
4. Organizational Leadership [Insert a number [Insert a number
[Auto-calculated]
between 0 – 99] between 0 – 99]
5. Board Governance [Insert a number [Insert a number
[Auto-calculated]
between 0 – 99] between 0 – 99]
6. Strategic Planning [Insert a number [Insert a number
[Auto-calculated]
between 0 – 99] between 0 – 99]
7. Human Resource [Insert a number [Insert a number
[Auto-calculated]
Management between 0 – 99] between 0 – 99]
8. Financial Operations & [Insert a number [Insert a number
[Auto-calculated]
Oversight between 0 – 99] between 0 – 99]
9. Data and Analysis [Insert a number [Insert a number
[Auto-calculated]
between 0 – 99] between 0 – 99]
D.3. Technical Assistance Plans and Quality Improvement Plans: In the table below, please provide
the number of CSBG Eligible Entities with unmet organizational standards with Technical
Assistance Plans (TAPs) or Quality Improvement Plans (QIPs) in place.
Technical Assistance Plans and Quality Improvement Plans
Total Number of CSBG Eligible Entities with unmet organizational [Insert a number
standards with Technical Assistance Plans (TAPs) in place between 0 – 99]
Total Number of CSBG Eligible Entities with unmet organizational [Insert a number
standards with Quality Improvement Plans (QIPs) in place between 0 – 99]
D.3.a. If the State identified CSBG Eligible Entities with unmet organizational standards for
which it was determined that TAPs or QIPs would not be appropriate, please provide a narrative
explanation below. [If no is selected – Narrative, 2500 characters]
Note: D.3 is associated with State Accountability Measure 6Sb. QIPs are described in Section 678C(a)(4)
of the CSBG Act. For additional information on corrective action and the circumstances under which a
State may establish TAPs and QIPs, see IM-138, Pages 5-6.
Module 1 Page 9 of 66
State Administration

SECTION E
State Use of Funds
Note: The reporting timeframes for expenditure information is based on the Federal Fiscal Year, which
runs from October 1 of a given calendar year until September 30 of the following calendar year. States
that operate according to a different fiscal year should analyze actual quarterly obligation of funds and
report on obligations made during the time period of the Federal Fiscal Year.
CSBG Eligible Entity Allocation (90 Percent Funds) [Section 675C(a) of the CSBG Act]
E.1. State Distribution Formula: Did the State institute any changes in the distribution formula for
the CSBG Eligible Entities during the reporting period covered by this report? Yes No
CSBG IS,
Section B, E.1a If yes, please describe any specific changes and describe how the State complied with
Question 3 assurances provided in Question 14 of the CSBG State Plan as required under Section
C76(b)(8) of the State CBSG Act.
[Narrative, 2500 characters]
E.2. Planned vs. Actual Allocation: Using the table below, specify the actual allocation of 90 percent
of CSBG funds to CSBG Eligible Entities, as described under Section 675C(a) of the CSBG
CSBG IS, Act. While the CSBG State Plan allows for either percentages or dollar amounts, this table in
Section A, the administrative report must be based on actual dollars allocated to each CSBG Eligible Entity
Question during the Federal Fiscal Year (FFY). For each CSBG Eligible Entity receiving CSBG funds, provide
2 the Funding Amount allocated to the CSBG Eligible Entity during the FFY.
Planned vs Actual CSBG 90 Percent Funds
Planned Actual
CSBG Eligible
Allocations
Entity Funding Amount ($ or %) Obligations
(Based on State Formula)
Information in Information in this cell will [Numeric response, specify [Numeric response,
this cell will be be auto-populated from $ amount] specify $ amount]
auto-populated the CSBG State Plan,
from the CSBG (Section 7, Table 7.2) and Enter the dollar amount Enter the actual dollar
State Plan cannot be updated or actually allocated to each amount obligated to
Section 5, Table changed. Amounts may CSBG Eligible Entity under each CSBG Eligible
5.1, Column 1 have been presented in the State formula for the Entity through
either a percentage or period covered in the contracts or
planned dollar amount. Federal Fiscal Year. subawards for the
period covered in the
Federal Fiscal Year.
Total Total will be auto- Total will be auto- Total will be auto-
calculated calculated calculated
Module 1 Page 10 of 66
State Administration

E.3. Actual Distribution Timeframe: Did the State make funds available to CSBG Eligible Entities no
later than 30 calendar days after OCS distributed the Federal award? Yes No
NEW
E.3a. If no, did the State implement procedures to ensure funds were made available to CSBG
Eligible Entities consistently and without interruption? Yes No
E.3b. If the State was not able to make CSBG funds available within 30 calendar days after
OCS distributed the Federal award and was not able to ensure that funds were made
available consistently and without interruption, provide an explanation of the
circumstances below along with a description of planned corrective actions.
[Narrative, 2500 Characters]
Note: Item E.3 is associated with State Accountability Measure 2Sa.
Administrative Funds [Section 675C(b)(2) of the CSBG Act]
E.4. What amount of State CSBG funds did the State obligate for administrative activities during the
Federal Fiscal Year? The amount must be based on actual dollars allocated during the Federal
CSBG IS, Fiscal Year (FFY). If you provided a percentage in Question 7.6 in the CSBG State Plan, please
Section A, convert to dollars.
Question 2b
State Administrative Funds
CSBG State Plan Actual Amount Obligated
[Auto-populated target [If entered in the CSBG State [Numeric response, specify $
from the CSBG State Plan Plan as a percentage, convert amount]
Question 7.6] and insert your number in
dollars here.]
[Narrative, 2500 Characters]
E.5. How many State staff positions were funded in whole or in part with CSBG funds in the
reporting period (FFY)? [Insert a number between 0 – 99]
CSBG IS, State Staff Positions Funded
Section C, CSBG State Plan Actual Number
Question 7a
[Auto-populated target from the [Insert a number between 0 – 99]
CSBG State Plan question 7.7].
Module 1 Page 11 of 66
State Administration

E.6. How many State Full Time Equivalents (FTEs) were funded with CSBG funds in the reporting
period (FFY)?
CSBG IS, State FTEs
Section C, CSBG State Plan Actual Number
Question 7b
[Auto-populated target from the [Insert a number between 0 – 99]
CSBG State Plan question 7.8].
Remainder/Discretionary Funds [Section 675C(b) of the CSBG Act]
E.7. Describe how the State used remainder/discretionary funds in the table below.
Instructional Note: While the CSBG State Plan allows for either percentages or dollar
CSBG IS, amounts, this table in the administrative report must be based on actual dollars obligated to
Section A, each budget category during the Federal Fiscal Year (FFY). States that do not have
Question 2c remainder/discretionary funds will not complete this item. If a funded activity fits under
and Section B, more than one category in the table, allocate the funds among the categories. For example, if
Question 5a-b the State provides funds under a contract with the State Community Action Association to
provide training and technical assistance to CSBG Eligible Entities and to create a statewide
data system, the funds for that contract should be allocated appropriately between Row a
and Row c. If an allocation is not possible, the State may allocate the funds to the main
category with which the activity is associated.
Note: This information is associated with State Accountability Measures 3Sa.
Planned vs. Actual Use of Remainder/Discretionary Funds
Remainder/ Planned Obligated
Discretionary Fund Brief description of
(See 675C(b)(1) Uses of the Planned $ Planned % Actual $ services/activities
CSBG Act)
Narrative 2500
a. Training/technical characters – Briefly
assistance to describe the actual
CSBG Eligible services and
Entities activities funded for
Information in these cells will [Enter actual $ for each each category.
b. Coordination of be auto-populated from the item listed for this Federal
State-operated accepted CSBG State plan and Fiscal Year. Narrative 2500
programs and/or cannot be updated or characters
local programs changed.
c. Statewide
coordination and Narrative 2500
communication characters
among CSBG
Eligible Entities
Module 1 Page 12 of 66
State Administration

Planned vs. Actual Use of Remainder/Discretionary Funds
Remainder/ Planned Obligated
Discretionary Fund Brief description of
(See 675C(b)(1) Uses of the Planned $ Planned % Actual $ services/activities
CSBG Act)
d. Analysis of
distribution of
CSBG funds to [Narrative, 2500
determine if characters]
targeting greatest
need
e. Asset-building [Narrative, 2500
programs characters]
f. Innovative
programs/
activities by CSBG Narrative, 2500
Eligible Entities or characters]
other
neighborhood
groups
g. State charity tax [Narrative, 2500
credits characters]
h. Other activities, [Narrative, 2500
specify_________ characters]
Totals Auto-calculated Auto-calculated
E.8. What types of organizations, if any, did the State work with (by grant or contract using
remainder/discretionary funds) to carry out some or all of the activities in table E.7 (above).
CSBG IS, [Check all that apply and provide a narrative where applicable]
Section B,
Question 5a CSBG Eligible Entities (if checked, include the expected number of CSBG Eligible Entities to
receive funds) [Narrative, 2500 characters]
Other community-based organizations
State Community Action association
Regional CSBG technical assistance provider(s)
National technical assistance provider(s)
Individual consultant(s)
Tribes and Tribal Organizations
Other [Narrative, 2500 characters]
None (the State will carry out activities directly)
Module 1 Page 13 of 66
State Administration

E.9. Total Obligations: Total CSBG funds obligated for the Federal Fiscal Year (Review and confirm
from the chart below).
CSBG
IS, Category Actual Obligations
Section Obligations to CSBG Eligible Entities (from State CSBG Auto-populated from Table E.2 (total
A, 90% Formula Funds) actual obligations in contracts and
Question subawards)
2
State Administrative Costs Auto-populated from Table E.4 (total
actual obligations of administrative funds)
CSBG IS, Section A, Question 2
Remainder/Discretionary Funds Auto-populated from Table E.7 (total
actual obligations of State
remainder/discretionary funds).
Total Obligations in FY ___ Total will be auto-calculated from the
three rows above
CSBG E.9a. Prior Year Carryover
IS, Of the total amount reported in the row above, the
[Numeric response, specify $ amount]
Section amount that represents carryover funding from the
A, prior fiscal year.
E.9b. Carryover for this Fiscal Year
Of the total CSBG amount to the State for this fiscal
[Numeric response, specify $ amount]
year, the amount that was unobligated and will carry
forward to the next fiscal year.
CSBG IS,
Section A,
Question 4
Module 1 Page 14 of 66
State Administration

SECTION F
State Training and Technical Assistance
F.1. Describe how the State delivered CSBG-funded training and technical assistance to CSBG
Eligible Entities by completing the table below. Add a row for each activity: indicate the
timeframe; whether it was training, technical assistance or both; and the topic. CSBG funding
CSBG IS, used for this activity is referenced under item E.7 (Planned vs. Actual Use of
Access Remainder/Discretionary Funds.)
Database,
T/TA Note: F.1 is associated with State Accountability Measure 3Sc.
[This table will be auto-populated with information provided in the State’s accepted CSBG
State plan and should be reviewed and updated based on the actual activities implemented.]
Training and Technical Assistance
Training, Technical
Topic Actual Dates Brief Description
Assistance, or Both
Auto-populated from Auto-populated from [Enter Date or Range] [Narrative, 2500 characters]
Table 8.1 of the CSBG Table 8.1 of the CSBG
State Plan State Plan Provide additional brief
• Training • Fiscal explanation of the technical
• Technical • Governance/Triparti assistance activities
Assistance te Boards implemented. If “Other" was
• Both • Organizational selected in column 3, describe
Standards – General in this column.
• Organizational
Standards – for
CSBG Eligible Entities
with unmet
standards on
Technical Assistance
Plans (TAPs) or
Quality
Improvement Plans
(QIPs)
• Correcting
Significant
Deficiencies Among
CSBG Eligible Entities
• Reporting
• ROMA
• Community
Assessment
• Strategic Planning
• Monitoring
• Communication
• Technology
• Other
ADD a ROW function Note: Rows may be added for each additional training
Module 1 Page 15 of 66
State Administration

F.2. Indicate the types of organizations through which the State provided training and/or technical
assistance as described in item F.1, and briefly describe their involvement? (Check all that
apply.) [Check all that applies and narrative where applicable]
CSBG IS, CSBG Eligible Entities (if checked, provide the expected number of CSBG Eligible Entities to
Access receive funds) [Narrative, 2500 characters]
Database and Other community-based organizations
Section B, State Community Action association
Question 5A Regional CSBG technical assistance provider(s)
National technical assistance provider(s)
Individual consultant(s)
Tribes and Tribal Organizations
Other [Narrative, 2500 characters]
Module 1 Page 16 of 66
State Administration

NEW: All of Section G and it will populate with the information entered into the State Plan
SECTION G
State Linkages and Communication
Note: This section describes activities that the State supported with CSBG remainder/discretionary
funds, described under Section 6 75C(b)(1) of the CSBG Act. Note: This item is associated with State
Accountability Measure 7Sa.
G.1. State Linkages and Coordination at the State Level: Please review and confirm the areas for
linkages and coordination that were outlined in the CSBG State Plan.
[The items below will be auto-populated based on responses to question 9.1. in the CSBG State
Plan and m ay be updated.]
State Low Income Home Energy Assistance Program (LIHEAP) office
State Weatherization office
State Temporary Assistance for Needy Families (TANF) office
State Head Start office
State public health office
State education department
State Workforce Innovation and Opportunity Act (WIOA) agency
State budget office
Supplemental N utrition Assistance Program ( SNAP)
State child welfare office
State housing office
Other
G.1a. Describe the linkages and coordination at the State level that the State created or
maintained to ensure increased access to CSBG services by communities and people with low-
incomes that avoid duplication of services (as required by the assurance under Section
676(b)(5)) and identified in the CSBG State Plan . Describe or attach additional information as
needed and provide a narrative describing activities including an explanation of any changes
from the original CSBG State Plan.
[Narrative - 2500 Characters]
G.2. State Linkages and Coordination at the Local Level: Describe the linkages and coordination at
the local level that the State created or maintained with governmental and other social
services, especially antipoverty programs, to assure the effective delivery of and coordination
of CSBG services to people with low-incomes and communities and avoid duplication of services
(as required by assurances under Sections 676(b)(5) and (b)(6)). Review a nd update the
narrative describing actual activities, including an explanation of any changes from the original
CSBG State Plan. Attach additional information as needed.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.2.
from CSBG State Plan. The State will review and update the narrative describing actual
activities, including an explanation of any changes from the original CSBG State Plan.]
Module 1 Page 17 of 66
State Administration

G.3. CSBG Eligible Entity Linkages and Coordination
G.3a State Assurance of CSBG Eligible Entity Linkages and Coordination: Describe how the
State assured that the CSBG Eligible Entities coordinated and established linkages to
assure the effective delivery of and coordination of CSBG services to people with low-
incomes and communities and avoid duplication of services (as required by the
assurance under Section 676(b)(5)). Attach additional information as needed.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.3.
from CSBG State Plan. The State will review and update the narrative describing actual
activities, including an explanation of any changes from the CSBG State plan.]
G.3b State Assurance of CSBG Eligible Entity Linkages to Fill Service Gaps: Describe how the
CSBG Eligible Entities developed linkages to fill identified gaps in the services, through
the provision of information, referrals, case management, and follow-up consultations,
according to the assurance under Section 676(b)(3)(B) of the CSBG Act.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.3b.
from CSBG State Plan. The State will review and update the narrative describing actual
activities, including an explanation of any changes from the original CSBG State Plan.]
G.4. Workforce Innovation and Opportunity Act (WIOA) Employment and Training Combined Plan
Activities (if applicable): If the State included CSBG employment and training activities as part
of a WIOA Combined State Plan, as allowed under the Workforce Innovation and Opportunity
Act, provide a brief narrative describing the status of WIOA coordination activities, including
web links, if available, to any publicly accessible combined plans and reports.
[Narrative, 2500 Characters]
[Note: This narrative box will only be completed by States in which CSBG employment and
training activities are included as part of a WIOA Combined State Plan. Because the WIOA
Combined State Plan is in a separate system not administered by ACF, information cannot be
auto-populated. The purpose of this section will be to provide an administrative update on State-
level WIOA plan coordination for States with combined plans, rather than a report on
employment and training outcomes at the CSBG Eligible Entity level. ]
G.5. Coordination among CSBG Eligible Entities and the State Community Action Association:
Describe State activities that took place to support coordination among the CSBG Eligible
Entities and the State Community Action Association.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.8. from CSBG
State Plan. The State will review and update the narrative describing actual activities, including
an explanation of any changes from the original CSBG State Plan.]
Module 1 Page 18 of 66
State Administration

G.6. Feedback to CSBG Eligible Entities and State Community Action Association: Describe how the
State provided feedback to local entities and the State Community Action Association regarding
its performance on State Accountability Measures.
[Narrative, 2500 Characters]
[This narrative box will be auto-populated with the actual response to question 9.10 from CSBG
State Plan. The State will review and update the narrative describing actual activities, including
an explanation of any changes from the original CSBG State Plan.]
Note: This information is associated with State Accountability Measure 5S(iii). The measure
indicates feedback should be provided within 60 calendar days of the State receiving feedback
from OCS.
Module 1 Page 19 of 66
State Administration

NEW: All of Section H and it will populate with the information entered into the State Plan
SECTION H
Monitoring, Corrective Action, and Fiscal Controls
Monitoring of CSBG Eligible Entities (Section 678B(a) of the CSBG Act)
H.1. Briefly describe the actual monitoring visits conducted during the reporting year including: full
on-site reviews; on-site reviews of newly designated entities; follow-up reviews – including
return visits to entities that failed to meet State goals, standards, and requirements; and other
reviews as appropriate. If a monitoring visit was planned during the year but not implemented,
provide a brief explanation in the far right column of the table below.
Note: This information is associated with State Accountability Measure 4Sa(i).
This table will be auto-populated with information provided in the State’s accepted CSBG
State Plan. The information should be reviewed and updated based on the actual monitoring
visits conducted. Additional rows may be added for monitoring visits that were not included
in the original plan with an explanation of the circumstances in the description. A brief
explanation for any visits that were included in the State plan but not conducted may be
provided in the far right row.
CSBG Eligible Entity Review Type Actual Site Brief Description of Purpose
Visit Dates
Information in these Dropdown
cells will be auto- Options:
populate with
projected visits in Table • Full onsite Note: If a monitoring visit was a part of the
10.1 from the CSBG • Newly original state monitoring plan, note it as a
State Plan. The State Designated scheduled monitoring visit. If the visit was not a
may add rows for • Follow-up part of the original monitoring plan, provide a
additional monitoring • Other brief explanation for the purpose of the visit (e.g.
visits conducted. The • No review Enter dates a follow-up regarding a special issue). This
State may not delete section should not be used to outline findings,
visits that were but should simply note the purpose of the
included in the CSBG monitoring (e.g. follow-up regarding corrective
State Plan, but may actions).
provide a brief [Narrative, 500 characters]
explanation for visits
that were not
conducted in the far
right row.
ADD a ROW function Note: Rows may be added for each additional Monitoring Visit
H.2. Monitoring Policies: Were any modifications made to the State’s monitoring policies and
procedures during the reporting period (FFY)? Yes  No
If changes were made to State monitoring policies and procedures, attach and/or provide a
hyperlink to the modified documents. [Attach a document or add a link]
H.3. Initial Monitoring Reports: Were all S tate monitoring reports conducted in manner consistent
with State monitoring policies and procedures and disseminated to CSBG Eligible Entities within
60 calendar days?  Yes  No
Module 1 Page 20 of 66
State Administration

If no, provide the actual number of days for initial distribution of all monitoring reports and
provide an explanation for the circumstances that resulted in delayed reports. [Narrative 2500
characters]
Note: This item is associated with State Accountability Measure 4Sa(ii).
Corrective Action, Termination and Reduction of Funding and Assurance Requirements (Section 678C
of the CSBG Act)
H.4. Quality Improvement Plans (QIPs): Did all CSBG Eligible Entities on Quality Improvement Plans
resolve identified deficiencies within the schedule agreed upon by the State and eligible entity?
Yes No
If no, provide an explanation for the circumstances. [Narrative 2500 characters]
Note: The QIP information is associated with State Accountability Measures 4Sc.
H.5. Reporting QIPs: Did the State report all CSBG Eligible Entities with serious deficiencies from a
monitoring review to the Office of Community Services within 30 calendar days of the State
approving a QIP? Yes No
If no, provide an explanation for the circumstances. A plan to assure timely notification of OCS
must be included in the next CSBG State Plan. [Narrative 2500 characters]
Note: This item is associated with State Accountability Measure 4Sa(iii)).
Fiscal Controls and Audits
H.6. Single Audit Review: In the table below, provide the dates of any CSBG Eligible Entity Single
Audits in the Federal Audit Clearinghouse that were received and reviewed during the Federal
Fiscal Year as required by the CSBG regulations applicable to 45 CFR 75.521. If the audit
contained findings requiring a management decision by the State, provide the date the decision
was issued.
Employer Date Audit Was State State Date
Identification Accepted by Management Management Management
Number (EIN) of Federal Audit Decision Decision Decision Issued
Agency Clearinghouse Required? Issued within (if applicable)
Six Months?
[Numeric] [Date] [Y/N] [Y/N/Pending] [Date]
Add a ROW function Note: Rows may be added for each additional Single Audit accepted by the Federal Audit
Clearinghouse during the fiscal year.
H.7. Single Audit Management Decisions: Briefly describe any management decisions issued
according to State procedures of CSBG Eligible Entity single audit. Provide the audit finding
reference number from the Federal Audit Clearinghouse and describe any required actions and
timelines for correction. [Narrative, 2500 Characters]
Note: This information is associated with State Accountability Measure 4Sd.
Module 1 Page 21 of 66
State Administration

NEW: All of Section I and it will populate with the information entered into the State Plan
SECTION I
Results Oriented Management and Accountability (ROMA) System
I.1. ROMA Participation: In which performance measurement system did the State and CSBG
Eligible Entities participate, as required by Section 678E(a) of the CSBG Act and the assurance
under Section 676(b)(12) of the CSBG Act?
Auto-populated from the CSBG State Plan. State will review and confirm
The Results Oriented Management and Accountability (ROMA) System
Another performance management system that meets the requirements of section 678E(b)
of the CSBG Act
An alternative system for measuring performance and results
I.1a. If ROMA was selected in item I.1, provide an update on any changes in procedures or to
data collection systems that were initiated or completed in the reporting period.
[Attachment and Narrative, 2500 characters]
I.1b. If ROMA was not selected in item I.1, describe the system the State used for
performance measurement. Provide an update on any changes in procedures or to data
collection systems that were initiated or completed in the reporting period.
[Narrative, 2500 characters]
I.2. State ROMA Support: How did the State support the CSBG Eligible Entities in using the ROMA
system or alternative performance measurement system in promoting continuous
improvement? For example, describe any data systems improvements, support for community
needs assessment, support for strategic planning, data analysis etc.
[Narrative, 2500 characters or attach a document]
I.3. State Review of CSBG Eligible Entity Data: Describe the procedures and activities the State
used to review the ROMA data (i.e. all data from elements of the ROMA cycle) from CSBG
Eligible Entities for completion and accuracy (e.g. methodology used for validating the data
submitted annually by the local agencies).
[Narrative, 2500 characters or attach a document]
I.4 State Feedback on Data Collection, Analysis, and Reporting: State Accountability Measure
5S(ii) requires states to submit written feedback to each CSBG Eligible Entity regarding the
entity’s performance in meeting ROMA goals, as measured through National Performance
Indicator (NPI) data, within 60 calendar days of submitting the State’s Annual Report. Has the
state provided each CSBG Eligible Entity written, timely (at a minimum within 60 days of the
submission) feedback regarding the entity’s performance in meeting ROMA goals as
measured through national performance data? Yes No
Module 1 Page 22 of 66
State Administration

If no, describe the plan to assure timely notification of the CSBG Eligible Entities within
60 calendar days of submitting the State’s CSBG Annual Report. [Narrative 2500
characters]
If yes, please describe.
Note: This information is associated with State Accountability Measure 5S(ii).
I.5. State and CSBG Eligible Entity Continuous Improvement. Provide 2-3 examples of changes
made by CSBG Eligible Entities to improve service delivery and enhance impact for individuals,
families, and communities with low-incomes based on their in-depth analysis of performance
data.
[Narrative, 2500 characters or attach a document]
Module 1 Page 23 of 66
State Administration

Module 2
CSBG Eligible Entity Expenditures,
Capacity, and Resources
Page 24 of 66

Module 2, Section A: CSBG Expenditures by CSBG Eligible Entity - Data Entry Form
Name of CSBG Eligible Entity Reporting: ___________________________________________
CSBG IS,
Section A. CSBG Eligible Entity Reporting Period "X"
A, 1. July 1 - June 30
Question 2. October 1 - September 30
1 3. January 1 - December 31
B. CSBG Expenditures Domains CSBG Funds
1. Employment CSBG IS, Section E, Table 1
2. Education and Cognitive Development
3. Income, Infrastructure, and Asset Building
4. Housing
5. Health and Social/Behavioral Development (includes nutrition) Revised
6. Civic Engagement and Community Involvement NEW
7. Services Supporting Multiple Domains Revised
8. Linkages (e.g. partnerships that support multiple domains) Revised
9. Agency Capacity Building (detailed below in Table C) NEW
10. Other (e.g. emergency management/disaster relief)
Total CSBG Expenditures (auto calculated) $0
CSBG IS,
Of the CSBG funds reported above, report the total amount used for Administration. For more information on Section E,
what qualifies as Administration, refer to IM37.
Table 1
C. Details on Agency Capacity Building Activities Funded by CSBG:
1. Please identify which activities were funded by CSBG under Agency Capacity in Table B. Please check all that apply.
Community Needs Assessment Data Management & Reporting Other* NEW
Strategic Planning Training & Technical Assistance
*Below please specify Other Activities funded by CSBG under Agency Capacity:
Module 2 Page 26 of 66
Section A: CSBG Expenditures by CSBG Eligible Entity

Module 2, Section B: CSBG Eligible Entity Capacity Building - Data Entry Form
Name of CSBG Eligible Entity: _________________________________________________________
A. CSBG Eligible Entity Reporting Period "X"
1. July 1 - June 30
auto-populated from Module
2. October 1 - September 30 2, Section A
3. January 1 - December 31
B. Hours of Agency Capacity Building (e.g. training, planning, assessment): Hours
1. Hours of Board Members in capacity building activities CSBG IS, NPI 5.1 E-H
2. Hours of Agency Staff in capacity building activities
C. Volunteer Hours of Agency Capacity Building (e.g. program support, service delivery, fundraising): Hours
1. Total number of volunteer hours donated to the agency CSBG IS, NPI 2.3.b and 3.1
a. Of the above, the total number of volunteer hours donated by individuals with low-incomes
D. The number of staff who hold certifications that increase agency capacity to achieve family and community
Number
outcomes, as measured by one or more of the following:
1. Number of Nationally Certified ROMA Trainers
2. Number of Nationally Certified ROMA Implementers
3. Number of Certified Community Action Professionals (CCAP)
4. Number of Staff with a child development certification
5. Number of Staff with a family development certification
6. Number of Pathways Reviewers
7. Number of Staff with Home Energy Professional Certifications
a. Number of Energy Auditors CSBG IS, NPI 5.1
b. Number of Retrofit Installer Technicians A-D and NEW
c. Number of Crew Leaders
d. Number of Quality Control Inspectors (QCI)
8. Number of LEED Risk Certified assessors
9. Number of Building Performance Institute (BPI) certified professionals
10. Number of Classroom Assessment Scoring System (CLASS) certified professionals
11. Number of Certified Housing Quality Standards (HQS) Inspectors
12. Number of American Institute of Certified Planners (AICP)
13. Other (Please specify others below):
E. Number of organizations, both public and private, that the CSBG Eligible Entity actively works with to expand Unduplicated Number of
resources and opportunities in order to achieve family and community outcomes: Organizations
1. Non-Profit
2. Faith Based
3. Local Government
4. State Government
CSBG IS, NPI 4.1
5. Federal Government
6. For-Profit Business or Corporation Column 1
7. Consortiums/Collaborations
8. School Districts
9. Institutions of Post-Secondary Education/Training
10. Financial/Banking Institutions
11. Health Service Organizations
12. Statewide Associations or Collaborations
Module 2 Page 27 of 66
Section B: CSBG Eligible Entity Capacity Building

CSBG IS, Section F
Module 2, Section C: Allocated Resources per CSBG Eligible Entity -
Data Entry Form
Name of CSBG Eligible Entity: _____________________________________
A. CSBG Eligible Entity Reporting Period "X"
1. July 1 - June 30
2. October 1 - September 30 auto-populated from Module 2, Section A
3. January 1 - December 31
B. Amount of FY 20XX CSBG allocated to reporting entity
C. Federal Resources Allocated (Other than CSBG)
1. Weatherization (DOE) (include oil overcharge $$ ) 1.
2. Health and Human Services (HHS)
a. LIHEAP - Fuel Assistance (include oil overcharge $$ ) 2a.
b. LIHEAP - Weatherization (include oil overcharge $$ ) 2b.
c. Head Start 2c.
d. Early Head Start 2d.
e. Older Americans Act 2e.
f. Social Services Block Grant (SSBG) 2f.
g. Medicare/Medicaid 2g.
h. Assets for Independence (AFI) 2h.
i. Temporary Assistance for Needy Families (TANF) 2i.
j. Child Care Development Block Grant (CCDBG) 2j.
k. Community Economic Development (CED) 2k.
l. Other HHS Resources
i. CFDA #: 2l.i
ii. CFDA #: 2l.ii
iii. CFDA #: 2l.iii
iv. CFDA #: 2l.iv
2l. Total Other HHS Resources (autocalculated) 2l. $ -
3. Department of Agriculture (USDA)
a. Special Supplemental Nutrition for Women, Infants, and Children (WIC) 3a.
b. All USDA Non-Food programs (e.g. rural development) 3b.
c. All other USDA Food programs 3c.
4. Department of Housing and Urban Development (HUD)
a. Community Development Block Grant (CDBG) - Federal, State, and Local 4a.
b. Section 8 4b.
c. Section 202 4c.
d. Home Tenant-Based Rental Assistance (HOME TBRA) 4d.
e. HOPE for Homeowners Program (H4H) 4e.
f. Emergency Solutions Grant (ESG) 4f.
g. Continuum of Care (CoC) 4g.
h. All other HUD programs, including homeless programs 4h.
5. Department of Labor (DOL)
a. Workforce Innovation and Opportunity Act (WIOA) *previously WIA 5a.
b. Other DOL Employment and Training programs 5b.
c. All other DOL programs 5c.
6. Corporation for National and Community Service (CNCS) programs 6.
7. Federal Emergency Management Agency (FEMA) 7.
8. Department of Transportation 8.
9. Department of Education 9.
10. Department of Justice 10.
11. Department of Treasury 11.
12. Other Federal Resources
i. CFDA #: 12.i
ii. CFDA #: 12.ii
iii. CFDA #: 12.iii
iv. CFDA #: 12.iv
13. Total Other Federal Resources (autocalculated) 13. $ -
14. Total: Non-CSBG Federal Resources Allocated (autocalculated) 14 $ -
Module 2
Page 28 of 66
Section C: Allocated Resources per CSBG Eligible Entity

D. State Resources Allocated
1. a. State appropriated funds used for the same purpose as Federal CSBG funds 1a.
b. State Housing and Homeless programs (include housing tax credits ) 1b.
c. State Nutrition programs 1c.
d. State Early Childhood Programs (e.g. Head Start, Day Care ) 1d.
e. State Energy programs 1e.
f. State Health programs 1f.
g. State Youth Development programs 1g.
h. State Employment and Training programs 1h.
i. State Senior programs 1i.
j. State Transportation programs 1j.
k. State Education programs 1k.
l. State Community, Rural and Economic Development programs 1l.
m. State Family Development programs 1m.
n. Other State Resources
i. 1n.i
ii. 1n.ii
iii. 1n.iii
iv. 1n.iv
1n. Total Other State Resources (autocalculated) 1n. $ -
2. Total: State Resources Allocated (autocalculated) 2. $ -
3. If any of these resources were also reported under Item 15 (Federal Resources), please estimate the 3.
amount.
E. Local Resources Allocated
1. a. Amount of unrestricted funds appropriated by local government 1a.
b. Amount of restricted funds appropriated by local government 1b.
c. Value of Contract Services 1c.
d. Value of in-kind goods/services received from local government 1d.
2. Total: Local Resources Allocated (autocalculated) 2. $ -
If any of these resources were also reported under Item 15 or 17 (Federal or State Resources), please
3. estimate the amount. 3.
F. Private Sector Resources Allocated
1. a. Funds from foundations, corporations, United Way, other nonprofits 1a.
b. Other donated funds 1b.
c. Value of other donated items, food, clothing, furniture, etc. 1c.
d. Value of in-kind services received from businesses 1d.
e. Payments by clients for services 1e.
f. Payments by private entities for goods or services for low income 1f.
clients or communities
2. Total: Private Sector Resources Allocated (autocalculated) 2. $ -
3. If any of these resources were also reported under Item 15, 17, or 20 (Federal, State or Local Resources), 3.
please estimate the amount.
G. Total Non-CSBG Resources Allocated: (Federal, State, Local & Private) (autocalculated) G. $ -
H. Total Resources in CSBG Eligible Entity (including CSBG) (autocalculated) H. $ -
Note : * All totals are autocalculated
Module 2
Page 29 of 66
Section C: Allocated Resources per CSBG Eligible Entity

Module 3
Community Level
Page 30 of 66

NEW
Instructional Notes
Module 3 - Community Level
Module 3, Section A: Community Initiative Status Form
CSBG Eligible Entities will complete the Community Initiative Status Form for the CSBG Eligible Entity identified
initiatives intended to achieve community level outcomes. This form provides a central place to report valuable
information about a single community initiative that started, continued, or ended during the current reporting
period. The information reported on the status form will be selected via a dropdown menu or written as a
narrative. In future reporting periods, CSBG Eligible Entities will update the status form based on the initiative's
progress. Please see additional notes below:
Problem Identification: CSBG Eligible Entities will provide information on how the problem was identified in
the Community Needs Assessment. This will include any data collected.
Issue/CSBG Community Domains: Select the domain(s) category(ies) that best describe the issue addressed
by the initiative. A full list is provided in the Status Form.
Ultimate Expected Outcomes: Select the indicator(s) from the Community Level NPIs (full list is found in
Section B) that measures the ultimate expected outcome of the initiative OR enter an "Other Outcome
Indicator".
Partnership Type: Select the partnership type from the choices provided. For example, a multi-partner
initiative includes the CSBG Eligible Entity and one or more partners.
Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
To facilitate the reporting, use, and learning from Community NPIs the Annual Report provides two types of
indicators (Counts of Change and Rates of Change). Based on the community-level work in which the CSBG
Eligible Entity is engaged, select the appropriate NPIs in either section. All the NPIs are optional and a category of
“other” exists for a CSBG Eligible Entity to create its own indicator if none of those provided captures what the
CSBG Eligible Entity is trying to achieve.
The first way to report impact is the Counts of Change indicators. These are basic measures that provide the
number of units being measured, e.g. jobs, houses, resources, etc. that have been added (created) or subtracted
(eliminated), and in some cases maintained, in the community the CSBG Eligible Entity has targeted.
The second way to report impact is the Rates of Change indicators. While requiring a bit more information, these
indicators tell the full story of the magnitude of the impact a community initiative (usually involving multiple
organizations) has had in a community.
Module 3
Instructional Notes Page 31 of 66

NEW
Module 3, Section A: Community Initiative Status Form
Name of CSBG Eligible Entity Reporting:
Use the dropdown menu to select the response where appropriate.
1. Initiative Name
2. Initiative Year 1-7+ years
3. Problem Identification Narrative
(Provide a narrative on the scope of the problem)
4. Goal/Agenda Narrative
(Provide a narrative on the goal/agenda)
5. Issue/CSBG Community Employment; Education and Cognitive Development; Income, Infrastructure,
Domains and Asset Building; Housing; Health and Social/Behavioral Development; or Civic
Engagement and Community Involvement
6. Ultimate Expected Outcome Community Level National Performance Indicators (NPIs)
(Reference the Community NPIs listed in Section B)
7. Identified Community
Neighborhood, City, School District, County, Service Area, State, Region, or Other
8. Expected Duration Narrative
(Provide the range in years, e.g. 1-3 years)
9. Partnership Type Independent CAA Initiative, CAA is the core organizer of multi-partner Initiative,
or CAA is one of multiple active investors and partners
10. Partners Narrative
(Provide a narrative on the key 1-3 partners)
11. Strategy(ies)
Select from the Community Level Strategies listed in Section C
12. Progress on
Outcomes/Indicators No Outcomes to Report, Interim Outcomes, Final Outcomes
13. Impact of Outcomes Narrative
(Provide additional information on the scope of the impact of these outcomes.
e.g. If an initiative created a health clinic, please describe how many individuals
and families are expected to be impacted.)
14. Outcomes/Indicators to Community Level National Performance Indicators (NPIs)
Report (Reference the Community NPIs listed in Section B)
15. Final Status Initiative Active, Initiative Ended Early, Initiative Ended as Planned, Completed
Still Delivering Value
16. Lessons Learned
Narrative
Module 3 Page 33 of 66
Section A: Community Initiative Status Form

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Employment Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Employment Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
Counts
of 1. Number of jobs created to increase opportunities for people with low incomes in the identified community.
Change 2. Number of job opportunities maintained in the identified community. Similar to CSBG IS, NPI 1.1 A - D
3. Number of “living wage ” jobs created in the identified community*.
4. Number of “living wage” jobs maintained in the identified community*.
5. Number of jobs created in the identified community with a benefit package.
*When reporting on indicators related to living wage, agencies can provide their own definition or select from national or locally-defined models. Please indicate the living wage definition used in the General Comment box.
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Employment Indicators - Please specify below. Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
Counts of
Change
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Employment Indicators (auto-populated) point used for baseline baseline (% auto calculated)
Rates of comparisons (Target % auto (% auto
(#) calculated) calculated)
Change
1. Percent decrease of the unemployment rate.
2. Percent decrease of the youth unemployment rate. NEW
3. Percent decrease of the underemployment rate.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Other Other Rates of Change for Employment Indicators (auto-populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
(#) calculated) calculated)
Change
General comments:
Module 3
Section B: Community NPIs - Employment Page 34 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Education and Cognitive Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Education and Cognitive Development Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
1. Number of accessible and affordable early childhood or pre-school education assets or resources added to the Similar to CSBG IS, NPI 6.3 C-D
identified community.
2. Number of accredited or licensed affordable child care facilities added in the identified community. NEW
3. Number of new Early Childhood Screenings offered to children (ages 0-5) of families with low-incomes in the
Counts Expands on CSBG IS, NPI 6.3.A
identified community.
of
Change 4. Number of accessible and affordable education assets or resources added for school age children in the
Expands on CSBG
identified community. (e.g., academic, enrichment activities, before/after school care, summer programs)
IS, NPI 2.1.G
5. Number of accessible and affordable post secondary education assets or resources added for newly graduating Expands on CSBG
youth in the identified community. (e.g. college tuition, scholarships, vocational training, etc.)
IS, NPI 2.1.I
6. Number of accessible and affordable basic or secondary education assets or resources added for adults in the Expands on CSBG
identified community. (e.g. literacy, ESL, ABE/GED, etc.)
IS, NPI 2.1.I
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Education and Cognitive Development Indicators - Please specify below. Community (#) Results target accuracy
Counts of (auto-populated) (#) (% auto calculated)
Change
Module 3
Section B: Community NPIs - Education and Cognitive Development Page 35 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Education and Cognitive Development Indicators
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Education and Cognitive Development (auto-populated) point used for baseline baseline (% auto calculated)
Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
1. Percent increase of children in the identified community who
are kindergarten ready.
2. Percent increase of children in the identified community at (or
above) the basic reading level.
3. Percent increase of children in the identified community at (or
above) the basic math level.
Rates of
Change 4. Percent increase in high school (or high school equivalency)
graduation rate in the identified community. NEW
5. Percent increase of the rate of youth in the identified
community who attend post-secondary education.
6. Percent increase of the rate of youth in the identified
community who graduate from post-secondary education.
7. Percent increase of adults in the identified community who
attend post-secondary education.
8. Percent increase of adults in the identified community who
graduate from post-secondary education.
9. Percent increase in the adult literacy rate in the identified
community .
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Education and Cognitive Community existing starting (#) change from (#) change from target accuracy
Other Development Indicators (auto populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
(#) calculated) calculated)
Change
General comments:
Module 3
Section B: Community NPIs - Education and Cognitive Development Page 36 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Infrastructure and Asset Building Indicators
Name of CSBG Eligible Entity Reporting:
Counts of Change for Infrastructure and Asset I.) Identified II.) Target III.) Actual IV.) Performance
Community (#) Results target accuracy
Building Indicators (auto-populated) (#) (% auto calculated)
1. Number of new accessible assets/resources created in the identified community:
a. Commercial
b. Financial
c. Technological/ Communications (e.g.
broadband)
Counts d. Transportation
of e. Recreational (e.g. parks, gardens, libraries)
Change f. Other Public Assets/Physical Improvements Expands on CSBG
2. Number of existing assets/resources made accessible to the identified community: IS, NPI 2.2 A - D
a. Commercial
b. Financial
c. Technological/ Communications (e.g.
broadband)
d. Transportation
e. Recreational (e.g. parks, gardens, libraries)
f. Other Public Assets/Physical Improvements
Other Counts of Change for Infrastructure and Asset I.) Identified II.) Target III.) Actual IV.) Performance
Other Community (#) Results target accuracy
Counts of Building Indicators - Please specify below. (auto populated) (#) (% auto calculated)
Change
Module 3
Section B: Community NPIs - Infrastructure and Asset Building Page 37 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Housing Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Housing Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
1. Number of safe and affordable housing units developed in the identified community (e.g. built or set aside units Similar to CSBG IS, NPI 2.1.C
Counts for people with low incomes).
of 2. Number of safe and affordable housing units maintained and/or improved through WAP or other rehabilitation Similar to CSBG IS, NPI 2.1.D
Change efforts in the identified community.
3. Number of shelter beds created in the identified community. NEW
4. Number of shelter beds maintained in the identified community. NEW
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Housing Indicators- Please specify below. Community (#) Results target accuracy
Counts of (auto-populated) (#) (% auto calculated)
Change
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Housing Indicators (auto-populated) point used for baseline baseline (% auto calculated)
comparisons (Target % auto (% auto
(#) calculated) calculated)
1. Percent decrease in the rate of homelessness in the identified
Rates of community.
Change 2. Percent decrease in the foreclosure rate in the identified
community. NEW
3. Percent increase in the rate of home ownership of people with
low incomes in the identified community.
4. Percent increase of affordable housing in the identified
community.
5. Percent increase of shelter beds in the identified community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Community existing starting (#) change from (#) change from target accuracy
Other Rates of Change for Housing Indicators (auto populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
Change (#) calculated) calculated)
General comments:
Module 3
Section B: Community NPIs - Housing Page 39 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Health and Social/Behavioral Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Target III.) Actual IV.) Performance
Counts of Change for Health and Social/Behavioral Indicators Community (#) Results target accuracy
(auto-populated) (#) (% auto calculated)
1. Number of accessible and affordable physical health assets or resources created in the identified community.
Counts
of 2. Number of accessible and affordable behavioral and mental health assets or resources created in the identified community. Greatly expands
Change on CSBG IS, NPI
3. Number of public safety assets and resources created in the identified community.
2.2 A - E
4. Number of accessible and affordable healthy food resources created in the identified community.
5. Number of activities designed to improve police and community relations within the identified community.
I.) Identified II.) Target III.) Actual IV.) Performance
Other Other Counts of Change for Health and Social/Behavioral Indicators- Please specify below. Community (#) Results target accuracy
Counts of (auto-populated) (#) (% auto calculated)
Change
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Physical Health, Wellbeing, and (auto-populated) point used for baseline baseline (% auto calculated)
Development Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
1. Percent decrease in infant mortality rate in the identified community.
Rates of
Change 2. Percent decrease in childhood obesity rate in the identified
community. NEW
3. Percent decrease in adult obesity rate in the identified community.
4. Percent increase in child immunization rate in the identified
community.
5. Percent decrease in uninsured families in the identified community.
Module 3
Section B: Community NPIs - Health and Social/Behavioral Page 40 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Health and Social/Behavioral Indicators
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Behavioral and Mental health, Emotional (auto-populated) point used for baseline baseline (% auto calculated)
Wellbeing, and Development Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
1. Percent decrease in the teen pregnancy rate in the identified
community.
2. Percent decrease in unplanned pregnancies in the identified
community.
Rates of 3. Percent decrease in substance abuse rate in the identified
Change community.(e.g. cigarettes, prescription drugs, narcotics, alcohol).
4. Percent decrease in domestic violence rate in the identified
community. NEW
5. Percent decrease in the child abuse rate in the identified community.
6. Percent decrease in the child neglect rate in the identified community.
7. Percent decrease in the elder abuse rate in the identified community.
8. Percent decrease in the elder neglect rate in the identified
community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Public Safety Indicators (auto populated) point used for baseline baseline (% auto calculated)
comparisons (Target % auto (% auto
(#) calculated) calculated)
Rates of 1. Percent decrease in recidivism rate in the identified community.
Change 2. Percent decrease in non-violent crime rate in the identified
community.
3. Percent decrease in violent crime rate in the identified community. NEW
4. Percent decrease in teens involved with the juvenile court system in
the identified community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Health and Social/Behavioral Community existing starting (#) change from (#) change from target accuracy
Other Indicators (auto populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
Change (#) calculated) calculated)
General comments:
Module 3
Section B: Community NPIs - Health and Social/Behavioral Page 41 of 66

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.
Civic Engagement and Community Involvement Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Civic Engagement and Community (auto-populated) point used for baseline baseline (% auto calculated)
Involvement Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
1. Percent increase of donated time to support the CSBG Eligible Entity's
delivery of services and/or implementation of strategies to address Expands on CSBG IS, NPI 2.3 and 3.1
Rates of conditions of poverty in the identified community.
Change 2. Percent increase of donated resources to support the CSBG Eligible Expands on CSBG IS, Section F, 22 a-d
Entity's delivery of services and/or implementation of strategies to
address conditions of poverty in the identified community.
3. Percent increase of people participating in public hearings, policy
forums, community planning, or other advisory boards related to the
Expands on CSBG IS, NPI 3.2.A
CSBG Eligible Entity's delivery of service and/or implementation of
strategies to address conditions of poverty in the identified community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Civic Engagement and Community Community existing starting (#) change from (#) change from target accuracy
Other Involvement Indicators (auto-populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
(#) calculated) calculated)
Change
General comments:
Module 3
Page 42 of 66
Section B: Goal 2 Community NPIs - Civic Engagement Community Involvement

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form
Goal 3: People with low-incomes are engaged and active in building opportunities in communities.
Civic Engagement and Community Involvement Indicators
Name of CSBG Eligible Entity Reporting:
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Community existing starting (#) change from (#) change from target accuracy
Rates of Change for Civic Engagement and Community (auto-populated) point used for baseline baseline (% auto calculated)
Involvement Indicators comparisons (Target % auto (% auto
(#) calculated) calculated)
Rates of
Change 1. Percent increase of people with low incomes who support the CSBG
Eligible Entity's delivery of service and/or implementation of strategies Expands on CSBG IS, NPI 3.1.A
to address conditions of poverty in the identified community.
2. Percent increase of people with low incomes who acquire and
Expands on CSBG IS, NPI 3.2.A
maintain leadership roles with the CSBG Eligible Entity or other
organizations within the identified community.
I.) Identified II.) Baseline III.) Target IV.) Expected % V.) Actual Results VI.) Actual % VII.) Performance
Other Rates of Change for Civic Engagement and Community Community existing starting (#) change from (#) change from target accuracy
Other Involvement Indicators (auto-populated) point used for baseline baseline (% auto calculated)
Rates of - Please specify below. comparisons (Target % auto (% auto
(#) calculated) calculated)
Change
General comments:
Module 3
Page 43 of 66
Section B: Goal 3 Community NPIs - Civic Engagement Community Involvement

Strategies are new, but the activities would have been previously reported in CSBG IS, NPI 2.1
or 2.2
Module 3, Section C: Community Strategies List
Employment Strategies
Minimum/Living Wage Campaign
Job Creation/Employment Generation
Job Fairs
Earned Income Tax Credit (EITC) Promotion
Commercial Space Development Expands on NPIs
Employer Education 2.1.A and B, 2.2.A
Employment Policy Changes
Employment Legislative Changes and NEW
Other Employment Strategy: (please specify)
Education and Cognitive Development Strategies
Preschool for All Campaign
Charter School Development
After School Enrichment Activities Promotion
Pre K-College/Community College Support
Children’s Trust Fund Creation Expands on NPIs
Scholarship Creation 2.1.F, G, I, 2.2.A
Child Tax Credit (CTC) Promotion and NEW
Adoption Child Care Quality Rating
Adult Education Establishment
Education and Cognitive Development Policy Changes
Education and Cognitive Development Legislative Changes
Other Education and Cognitive Development Strategy: (please specify)
Infrastructure and Asset Building Strategies
Cultural Asset Creation
Police/Community Relations Campaign
Neighborhood Safety Watch Programs
Anti-Predatory Lending Campaign
Asset Building and Savings Promotion
Develop/Build/Rehab Spaces
Maintain or Host Income Tax Preparation Sites
Community-Wide Data Collection Systems Development Expands on NPI
Local 211 or Resource/Referral System Development 2.2 A-E and NEW
Water/Sewer System Development
Community Financial Institution Creation
Infrastructure Planning Coalition
Park or Recreation Creation and Maintenance
Rehabilitation/Weatherization of Housing Stock
Community Center/Community Facility Establishment
Asset Limit Barriers for Benefits Policy Changes
Infrastructure and Asset Building Policy Changes
Infrastructure and Asset Building Legislative Changes
Other Infrastructure and Asset Building Strategy: (please specify)
Module 3
Section C: Community Strategies List Page 44 of 66

Module 3, Section C: Community Strategies List
Housing Strategies
End Chronic Homelessness Campaign
New Affordable Single Unit Housing Creation
New Affordable Multi- Unit Housing Creation (Single Resident Occupancy (SRO), temporary housing, transitional housing)
Tenants’ Rights Campaign Expands on NPI
New Shelters Creation (including day shelters and domestic violence shelters)
Housing or Land Trust Creation 2.1 D-E, 2.2.A and
Building Codes Campaign NEW
Housing Policy Changes
Housing Legislative Changes
Other Housing Strategy: (please specify)
Health and Social/Behavioral Development Strategies
Health Specific Campaign
Farmers Market or Community Garden Development
Grocery Store Development
Gun Safety/Control Campaign
Healthy Food Campaign
Nutrition Education Collaborative
Food Bank Development Expands on NPI
Domestic Violence Court Development
2.1.E, 2.2 A-E and
Drug Court Development
Alternative Energy Source Development NEW
Develop or Maintain a Health Clinic
Health and Social/Behavioral Development Policy Changes
Health and Social/Behavioral Development Legislative Changes
Other Health and Social/Behavioral Development Strategy: (please specify)
Community Support Strategies
Off-Hours (Non-Traditional Hours) Child Care Development
Transportation System Development
Transportation Services Coordination and Support Expands on NPI
Community Support Policy Changes 2.1.H, 2.2.A and
Community Support Legislative Changes NEW
Other Community Support Strategy: (please specify)
Emergency Management Strategies
State or Local Emergency Management Board Enhancement
Community wide Emergency Disaster Relief Service Creation Expands on NPI
Disaster Preparation Planning
2.2.C and NEW
Emergency Management Policy Changes
Emergency Management Legislative Changes
Other Emergency Management Strategy: (please specify)
Module 3
Section C: Community Strategies List Page 45 of 66

Module 3, Section C: Community Strategies List
Civic Engagement and Community Involvement Strategies- Goal 2
Development of Health and Social Service Provider Partnerships
Recruiting and Coordinating Community Volunteers
Poverty Simulations
Attract Capital Investments
Expands on NPI
Build/Support Increased Equity
Equity Awareness Campaign 2.1.A, E and NEW
Coordinated Community-wide Needs Assessment
Civic Engagement and Community Involvement in Advocacy Efforts
Civic Engagement Policy Changes
Civic Engagement Legislative Changes
Other Civic Engagement and Community Involvement Strategy: (please specify)
Civic Engagement and Community Involvement Strategies — Goal 3
Empowerment of Individuals/Families with Low-Incomes
Campaign to Ensure Individuals with Low-Incomes are Represented on Local Governing Bodies
Social Capital Building Campaign for Individuals/Families with Low-Incomes
Campaign for Volunteer Placement and Coordination Expands on 2.1.A
Civic Engagement Policy Changes
Civic Engagement Legislative Changes and NEW
Other Civic Engagement and Community Involvement Strategy: (please specify)
Module 3
Section C: Community Strategies List Page 46 of 66

Module 4
Individual and Family Level
Page 47 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Employment Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Employment in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
1. The number of unemployed youth who obtained
#DIV/0! #DIV/0!
employment to gain skills or income.
2. The number of unemployed adults who obtained
#DIV/0! #DIV/0!
employment (up to a living wage).
3. The number of unemployed adults who obtained and
maintained employment for at least 90 days #DIV/0! #DIV/0!
(up to a living wage).
4. The number of unemployed adults who obtained and Expands on NPI
maintained employment for at least 180 days 1.1.A, B, and #DIV/0! D #DIV/0!
(up to a living wage).
5. The number of unemployed adults who obtained
#DIV/0! #DIV/0!
employment (with a living wage or higher).
6. The number of unemployed adults who obtained and
maintained employment for at least 90 days #DIV/0! #DIV/0!
(with a living wage or higher).
7. The number of unemployed adults who obtained and
maintained employment for at least 180 days #DIV/0! #DIV/0!
(with a living wage or higher).
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Employment in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
8. The number of employed participants in a career-
advancement related program who entered or
#DIV/0! #DIV/0!
transitioned into a position that provided increased
income and/or benefits.
a. Of the above, the number of employed participants
who Increased income from employment through #DIV/0! #DIV/0!
wage or salary amount increase. Expands on NPI
b. Of the above, the number of employed participants 1.1.C
who increased income from employment through #VALUE! #DIV/0!
hours worked increase.
c. Of the above, the number of employed participants
#DIV/0! #DIV/0!
who increased benefits related to employment.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Other Employment Outcome Indicator in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
9. The number of individuals or households
#DIV/0! #DIV/0!
______________.
Comments:
Module 4
Section A: Individual and Family NPIs - Employment Page 50 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Education and Cognitive Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Education and Cognitive Development Served Outcome (III/II = V] (% auto
in program(s) (#) [III/ I = IV ] (% calculated)
auto calculated)
1. The number of children (0 to 5) who demonstrated improved
#DIV/0! #DIV/0!
emergent literacy skills.
2. The number of children (0 to 5) who demonstrated skills for
school readiness. Expands on NPI #DIV/0! #DIV/0!
3. The number of children and youth who demonstrated improved 6.3.C, D and I
positive approaches toward learning, including improved attention 0 0 0 #DIV/0! #DIV/0!
skills. (auto total).
a. Early Childhood Education (ages 0-5) #DIV/0! #DIV/0!
b. 1st grade-8th grade #DIV/0! #DIV/0!
c. 9th grade-12th grade #DIV/0! #DIV/0!
4. The number of children and youth who are achieving at basic
grade level (academic, social, and other school success skills). (auto 0 0 0 #DIV/0! #DIV/0!
total)
a. Early Childhood Education (ages 0-5) #DIV/0! #DIV/0!
b. 1st grade-8th grade #DIV/0! #DIV/0!
c. 9th grade-12th grade #DIV/0! #DIV/0!
5. The number of parents/caregivers who improved their home Expands NPI 6.3.J #DIV/0! #DIV/0!
environments.
6. The number of adults who demonstrated improved basic and K
#DIV/0! #DIV/0!
education.
7. The number of individuals who obtained a high school diploma
#DIV/0! #DIV/0!
and/or obtained an equivalency certificate or diploma.
8. The number of individuals who obtained a recognized credential,
certificate, or degree relating to the achievement of educational or Expands NPI #DIV/0! 1.2.B #DIV/0!
vocational skills.
and C
9. The number of individuals who obtained an Associate’s degree. #DIV/0! #DIV/0!
10. The number of individuals who obtained a Bachelor’s degree. #DIV/0! #DIV/0!
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Education and Cognitive Development Outcome Served Outcome (III/II = V] (% auto
Indicator in program(s) (#) [III/ I = IV ] (% calculated)
auto calculated)
11. The number of individuals or households ______________. #DIV/0! #DIV/0!
Comments:
Module 4
Section A: Individual and Family NPIs - Education Page 51 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Income and Asset Building Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Income and Asset Building Served Outcome (III/II = V] (% auto
in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
1. The number of individuals who achieved and maintained
#DIV/0! #DIV/0!
capacity to meet basic needs for 90 days.
NEW
2. The number of individuals who achieved and maintained
#DIV/0! #DIV/0!
capacity to meet basic needs for 180 days.
3. The number of individuals who opened a savings CSBG IS, NPI 1.3.E
#DIV/0! #DIV/0!
account or IDA.
4. The number of individuals who increased their savings. CSBG IS, NPI 1.3.F #DIV/0! #DIV/0!
5. The number of individuals who used their savings to
#DIV/0! #DIV/0!
purchase an asset.
a. Of the above, the number of individuals who
CSBG IS, NPI 1.3.I #DIV/0! #DIV/0!
purchased a home.
6. The number of individuals who improved their credit NEW
#DIV/0! #DIV/0!
scores.
7. The number of individuals who increased their net
NEW #DIV/0! #DIV/0!
worth.
8. The number of individuals engaged with the Community
NEW #DIV/0! #DIV/0!
Action Agency who report improved financial well-being.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Served Outcome (III/II = V] (% auto
Other Income and Asset Building Outcome Indicator calculated)
in program(s) (#) [III/ I = IV ] (% auto
calculated)
9. The number of individuals or households
#DIV/0! #DIV/0!
______________.
Comments:
Module 4
Section A: Individual and Family NPIs - Income and Assets Page 52 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Housing Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Housing Served Outcome (III/II = V] (% auto
in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
1. The number of households experiencing homelessness
who obtained safe temporary shelter. CSBG IS, NPI 6.2.E #DIV/0! #DIV/0!
2. The number of households who obtained safe and
#DIV/0! #DIV/0!
affordable housing.
3. The number of households who maintained safe and
#DIV/0! #DIV/0!
affordable housing for 90 days. Combines and Expands CSBG IS, NPI
4. The number of households who maintained safe and
1.2.H and 6.4.E #DIV/0! #DIV/0!
affordable housing for 180 days.
5. The number of households who avoided eviction. #DIV/0! #DIV/0!
6. The number of households who avoided foreclosure. #DIV/0! #DIV/0!
7. The number of households who experienced improved
health and safety due to improvements within their home
(e.g. reduction or elimination of lead, radon, carbon NEW #DIV/0! #DIV/0!
dioxide and/or fire hazards or electrical issues, etc).
8. The number of households with improved energy NEW
#DIV/0! #DIV/0!
efficiency and/or energy burden reduction in their homes.
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Housing Outcome Indicator Served Outcome (III/II = V] (% auto
in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
9. The number of individuals or households
#DIV/0! #DIV/0!
______________.
Comments:
Module 4
Section A: Individual and Family NPIs - Housing Page 53 of 66

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve economic security.
Health and Social/Behavioral Development Indicators
Name of CSBG Eligible Entity Reporting:
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Health and Social/Behavioral Development Served Outcome (III/II = V] (% auto
in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
1. The number of individuals who demonstrated increased
#DIV/0! #DIV/0!
nutrition skills (e.g. cooking, shopping, and growing food).
2. The number of individuals who demonstrated improved
#DIV/0! #DIV/0!
physical health and well-being. NEW
3. The number of individuals who demonstrated improved
#DIV/0! #DIV/0!
mental and behavioral health and well-being.
4. The number of individuals who improved skills related Expands on CSBG IS #DIV/0! NPI 6.3.J #DIV/0!
to the adult role of parents/ caregivers.
5. The number of parents/caregivers who demonstrated
increased sensitivity and responsiveness in their #DIV/0! #DIV/0!
interactions with their children.
6. The number of seniors (65+) who maintained an
#DIV/0! #DIV/0!
independent living situation.
7. The number of individuals with disabilities who NEW
#DIV/0! #DIV/0!
maintained an independent living situation.
8. The number of individuals with chronic illness who
#DIV/0! #DIV/0!
maintained an independent living situation.
9. The number of individuals with no recidivating event for
0 0 0 #DIV/0! #DIV/0!
six months.
a. Youth (ages 14-17) #DIV/0! #DIV/0!
b. Adults (ages 18+) #DIV/0! #DIV/0!
I.) Number of II.) Target (#) III.) Actual IV.) Percentage V.) Performance
Participants Results (#) Achieving Target Accuracy
Other Health and Social/Behavioral Development Served Outcome (III/II = V] (% auto
Outcome Indicator in program(s) (#) [III/ I = IV ] (% auto calculated)
calculated)
10. The number of individuals or households
#DIV/0! #DIV/0!
______________.
Comments:
Module 4
Section A: Individual and Family NPIs - Health and Social/Behavioral Page 54 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable
and achieve economic security.
Employment Services
Name of CSBG Eligible Entity Reporting:
Employment Services Unduplicated Number of
Individuals Served
Skills Training and Opportunities for Experience
Vocational Training
On-the-Job and other Work Experience
Youth Summer Work Placements
Apprenticeship/Internship
Self-Employment Skills Training
Job Readiness Training
Career Counseling
Workshops
Expands on CSBG
Coaching
IS, NPI 1.2.A
Job Search
Coaching
Resume Development
Interview Skills Training
Job Referrals
Job Placements
Pre-employment physicals, background checks, etc.
Post Employment Supports
Coaching
Interactions with employers
Employment Supplies
Employment Supplies
Module 4
Section B: Employment Services Page 57 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable
and achieve economic security.
Education and Cognitive Development Services
Name of CSBG Eligible Entity Reporting:
Education and Cognitive Development Services Unduplicated Number of
Individuals Served
Child/Young Adult Education Programs
Early Head Start
Head Start
Other Early-Childhood (0-5 yr. old) Education
K-12 Education NEW and Expands
K-12 Support Services on CSBG IS, NPI
Financial Literacy Education 6.3 and 1.2
Literacy/English Language Education
College-Readiness Preparation/Support
Other Post Secondary Preparation
Other Post Secondary Support
School Supplies
School Supplies NEW
Extra-curricular Programs
Before and After School Activities
Summer Youth Recreational Activities
Summer Education Programs
NEW and Expands
Behavior Improvement Programs (attitude, self-
esteem, Dress-for-Success, etc.) on CSBG IS, NPI
Mentoring 1.2.D
Leadership Training
Adult Education Programs
Adult Literacy Classes
English Language Classes
Basic Education Classes
High School Equivalency Classes NEW and Expands
Leadership Training on CSBG IS, NPI
Parenting Supports (may be a part of the early 1.2 A-C
childhood programs identified above)
Applied Technology Classes
Post-Secondary Education Preparation
Financial Literacy Education
Post-Secondary Education Supports
College applications, text books, computers, etc. NEW
Financial Aid Assistance
Scholarships NEW
Home Visits
Home Visits NEW
Module 4
Module 4, Section B: Education and Cognitive Development Services Page 58 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and
achieve economic security.
Income and Asset Building Services
Name of CSBG Eligible Entity Reporting:
Income and Asset Building Services Unduplicated Number of
Individuals Served
Training and Counseling Services
Financial Capability Skills Training
Financial Coaching/Counseling
Financial Management Programs (including budgeting, credit
management, credit repair, credit counseling, etc.) NEW
First-time Homebuyer Counseling
Foreclosure Prevention Counseling
Small Business Start-Up and Development Counseling
Sessions/Classes
Benefit Coordination and Advocacy
Child Support Payments CSBG IS, NPI 1.3.B
Health Insurance
Social Security/SSI Payments
Veteran's Benefits NEW
TANF Benefits
SNAP Benefits
Asset Building
Saving Accounts/IDAs and other asset building accounts CSBG IS, NPI 1.3.D
Other financial products (IRA accounts, MyRA, other
NEW
retirement accounts, etc.)
VITA, EITC, or Other Tax Preparation programs CSBG IS, NPI 1.3.A
Loans And Grants
Micro-loans NEW
Business incubator/business development loans
Module 4
Section B: Income and Asset Building Services Page 59 of 66

Module 4, Section B: Individual and Family Services - Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and achieve
economic security.
Housing Services
Name of CSBG Eligible Entity Reporting:
Housing Services Unduplicated Number of
Individuals Served
Housing Payment Assistance
Financial Capability Skill Training NEW
Financial Coaching/Counseling
Rent Payments (includes Emergency Rent Payments) CSBG IS, NPI 6.2.C
Deposit Payments NEW
Mortgage Payments (includes Emergency Mortgage Payments)
Eviction Prevention Services
Eviction Counseling
Landlord/Tenant Mediations NEW
Landlord/Tenant Rights Education
Utility Payment Assistance
Utility Payments (LIHEAP-includes Emergency Utility Payments) Combines CSBG IS, NPI
Utility Deposits 1.2.J and K, 6.2.B and
Utility Arrears Payments 6.4.G and I
Level Billing Assistance NEW
Housing Placement/Rapid Re-housing
Temporary Housing Placement (includes Emergency Shelters)
Transitional Housing Placements NEW
Permanent Housing Placements
Rental Counseling
Housing Maintenance & Improvements
Home Repairs (e.g. structural, appliance, heating systems. etc.) CSBG IS 6.2.D
(Including Emergency Home Repairs)
Weatherization Services
Independent-living Home Improvements (e.g. ramps, tub and
shower grab bars, handicap accessible modifications, etc.)
Combines and
Healthy Homes Services(e.g. reduction or elimination of lead, Expands CSBG IS,
radon, carbon dioxide and/or fire hazards or electrical issues, NPI 1.2.K, 6.2.D
etc.) and 6.4.H
Energy Efficiency Improvements (e.g. insulation, air sealing,
furnace repair, etc.)
Module 4
Section B: Housing Services Page 60 of 66

Module 4, Section B: Individual and Family Services -
Data Entry Form
Goal 1: Individuals and Families with low incomes are stable and
achieve economic security.
Health and Social/Behavioral Development
Name of CSBG Eligible Entity Reporting:
Health and Social/Behavioral Development Services Unduplicated Number of
Individuals Served
Health Services, Screening and Assessments
Immunizations
Physicals
Developmental Delay Screening
Vision Screening Combines and
Prescription Payments Expands NPI
Doctor Visit Payments 1.2.G, 6.2.F, 6.3.A
Maternal/Child Health and 6.4.D
Nursing Care Sessions
In-Home Affordable Seniors/Disabled Care Sessions
(Nursing, Chores, Personal Care Services)
Health Insurance Options Counseling
Reproductive Health Services
Coaching Sessions
Family Planning Classes
NEW
Contraceptives
STI/HIV Prevention Counseling Sessions
STI/HIV Screenings
Wellness Education
Wellness Classes (stress reduction, medication management,
mindfulness, etc.) NEW
Exercise/Fitness
Mental/Behavioral Health
Detoxification Sessions
Substance Abuse Screenings
Substance Abuse Counseling
Mental Health Assessments NEW
Mental Health Counseling
Crisis Response/Call-In Responses
Domestic Violence Programs
Support Groups
Substance Abuse Support Group Meetings
Domestic Violence Support Group Meetings NEW
Mental Health Support Group Meeting
Module 4
Section B: Health and Social/Behavioral Development Services Page 61 of 66

CSBG IS, Section G and NEW
Module 4, Section C: All Characteristics Report - Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.
Name of CSBG Eligible Entity Reporting:
A. Total unduplicated number of all INDIVIDUALS about whom one or more characteristics were obtained:
B. Total unduplicated number of all HOUSEHOLDS about whom one or more characteristics were obtained:
C. INDIVIDUAL LEVEL CHARACTERISTICS
1. Gender Number of Individuals 6. Ethnicity/Race Number of Individuals
a. Male I. Ethnicity
b. Female a. Hispanic, Latino or Spanish Origins
c. Other b. Not Hispanic, Latino or Spanish Origins
d. Unknown/not reported c. Unknown/not reported
TOTAL (auto calculated) 0 TOTAL (auto calculated) 0
2. Age Number of Individuals II. Race
a. 0-5 a. American Indian or Alaska Native
b. 6-13 b. Asian
c. 14-17 c. Black or African American
d. 18-24 d. Native Hawaiian and Other Pacific Islander
e. 25-44 e. White
f. 45-54 f. Other
g. 55-59 g. Multi-race (two or more of the above)
h. 60-64 h. Unknown/not reported
i. 65-74 TOTAL (auto calculated) 0
j. 75+
k. Unknown/not reported 7. Military Status Number of Individuals
TOTAL (auto calculated) 0 a. Veteran
b. Active Military
3. Education Levels Number of Individuals c. Unknown/not reported
[ages 14-24] [ages 25+] TOTAL (auto calculated) 0
a. Grades 0-8
b. Grades 9-12/Non-Graduate 8. Work Status (Individuals 18+) Number of Individuals
c. High School Graduate/ Equivalency Diploma a. Employed Full-Time
d. 12 grade + Some Post-Secondary b. Employed Part-Time
e. 2 or 4 years College Graduate c. Migrant Seasonal Farm Worker
f. Graduate of other post-secondary school d. Unemployed (Short-Term, 6 months or less)
g. Unknown/not reported e. Unemployed (Long-Term, more than 6 months)
TOTAL (auto calculated) 0 0 f. Unemployed (Not in Labor Force)
g. Retired
4. Disconnected Youth Number of Individuals h. Unknown/not reported
a. Youth ages 14-24 who are neither working or in school TOTAL (auto calculated) 0
5. Health Number of Individuals
Yes No Unknown
a. Disabling Condition
Yes No Unknown
b. Health Insurance*
*If an individual reported that they had Health Insurance please identify the source of health
insurance below.
Health Insurance Sources
i. Medicaid
ii. Medicare
iii. State Children’s Health Insurance Program
iv. State Health Insurance for Adults
v. Military Health Care
vi. Direct-Purchase
vii. Employment Based
viii. Unknown/not reported
TOTAL (auto calculated) 0
Module 4 Page 65 of 66
Section C: All Characteristics Report

Module 4, Section C: All Characteristics Report - Data Entry Form
Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.
Name of CSBG Eligible Entity Reporting:
D. HOUSEHOLD LEVEL CHARACTERISTICS
9. Household Type Number of Households 13. Sources of Household Income Number of Households
a. Single Person a. Income from Employment Only
b. Two Adults NO Children b. Income from Employment and Other Income Source
c. Single Parent Female c. Income from Employment, Other Income Source,
d. Single Parent Male and Non-Cash Benefits
e. Two Parent Household d. Income from Employment and Non-Cash Benefits
f. Non-related Adults with Children e. Other Income Source Only
g. Multigenerational Household f. Other Income Source and Non-Cash Benefits
h. Other g. No Income
i. Unknown/not reported h. Non-Cash Benefits Only
TOTAL (auto calculated) 0 i. Unknown/not reported
TOTAL (auto calculated) 0
10. Household Size Number of Households Below, please report the types of Other income and/or non-cash benefits received by
a. Single Person the households who reported sources other than employment
b. Two 14. Other Income Source Number of Households
c. Three a. TANF
d. Four b. Supplemental Security Income (SSI)
e. Five c. Social Security Disability Income (SSDI)
f. Six or more d. VA Service-Connected Disability Compensation
g. Unknown/not reported e. VA Non-Service Connected Disability Pension
TOTAL (auto calculated) 0 f. Private Disability Insurance
g. Worker’s Compensation
11. Housing Number of Households h. Retirement Income from Social Security
a. Own i. Pension
b. Rent j. Child Support
c. Other permanent housing k. Alimony or other Spousal Support
d. Homeless l. Unemployment Insurance
e. Other m. EITC
f. Unknown/not reported n. Other
TOTAL (auto calculated) 0 o. Unknown/not reported
12. Level of Household Income Number of Households 15. Non-Cash Benefits Number of Households
(% of HHS Guideline) a. SNAP
a. Up to 50% b. WIC
b. 51% to 75% c. LIHEAP
c. 76% to 100% d. Housing Choice Voucher
d. 101% to 125% e. Public Housing
e. 126% to 150% f. Permanent Supportive Housing
f. 151% to 175% g. HUD-VASH
g. 176% to 200% h. Childcare Voucher
h. 201% to 250% i. Affordable Care Act Subsidy
i. 250% and over j. Other
j. Unknown/not reported k. Unknown/not reported
TOTAL (auto calculated) 0
E. Number of Individuals Not Included in the Totals Above (due to data collection system integration barriers)
1. Please list the unduplicated number of INDIVIDUALS served in each program*: Program Name Number of Individuals
F. Number of Households Not Included in the Totals Above (due to data collection system integration barriers)
1. Please list the unduplicated number of HOUSEHOLDS served in each program*: Program Name Number of Households
*The system will add rows to allow reporting on multiple programs.
Module 4 Page 66 of 66
Section C: All Characteristics Report

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average 203 hours per response for State
CSBG Lead Agencies and 756 hours per response for eligible entities, including the time for reviewing
instructions, gathering and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please send to: infocollection@acf.hhs.gov

Division of Aging and Adult Services
ALERT
SFY-18-L
Draft CSBG and LIHEAP State Plans for Comment
for SFY 2018
Please ensure that all appropriate CAN staff is provided with this information.
CSBG and LIHEAP State Plans
The draft FFY 2018 CSBG State Plan Amendment Attachment #1 and the LIHEAP State Plan for
FFY 2018 Attachment #4 are provided for Network review. The document format is not aligned
accurately, as it was converted from a PDF document into a Word document. Some of the boxes
and text are not in the correct spots.
Change matrices that outline the modifications made from last year’s Plans are also included in
Attachment #2 for CSBG, and Attachment #5 for LIHEAP.
The Division of Aging and Adult Services (DAAS) requests that the Network review the draft CSBG
FFY 2018 State Plan Amendment and draft FFY 2018 LIHEAP State Plan, and provide a final
group response on each matrix in the “Network’s Comment” column no later than, April 28, 2017.
DAAS anticipates posting the revised drafts of the FFY 2018 CSBG State Plan Amendment and
the LIHEAP State Plan for FFY 2018, on the Department of Economic Security’s Website for public
inspection no later than May 15, 2017. The combined public hearing is expected to be held in late
June, 2017, to allow a minimum of 30 days for public inspection of the State Plans prior to the
hearing.
For the CSBG State Plan, see also attached revised CSBG Funding Formula Attachment 3
and revised CSBG Organizational Standards Draft Policy, Attachment #1A
The Public Hearing for both plans will convene as follows:
Date/Time Location Topic
Phoenix Room TBD - Executive Tower CSBG and LIHEAP
TBD Late June 2017 1700 West Washington State Plans
1:00 -3:00 pm Street, Phoenix, AZ 85007
The Legislative Hearing for CSBG will be held in the following location and date:
Date/Time Location Topic
Phoenix Room TBD – State Legislative Complex CSBG State Plans
TBD Early-Mid 1700 West Washington Street, Phoenix,
August 2017 AZ 85007
Time: TBD
Should you have any questions or require additional information, please contact Sabrina Freeman
at 602-542-6620, SFreeman@azdes.gov for LIHEAP and Diana Gravett, 602-542-6594,
DGravett@azdes.gov for CSBG.

SFY-18-L Attachment #1
Form Approved
OMB No: 0970-0382
Expires: 07/31/2018
Community Services Block Grant (CSBG) Model State Plan
Federal Fiscal Years (FFYs) 2017-2018
Table of Contents
CSBG Cover Page (SF-424M)
Section 1: CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact, and Official State
Designation Letter
Section 2: State Legislation and Regulation
Section 3: State Plan Development and Statewide Goals
Section 4: CSBG Hearing Requirements
Section 5: CSBG Eligible Entities
Section 6: Organizational Standards for Eligible Entities
Section 7: State Use of Funds
Section 8: State Training and Technical Assistance
Section 9: State Linkages and Communication
Section 10: Monitoring, Corrective Action, and Fiscal Controls
Section 11: Eligible Entity Tripartite Board
Section 12: Individual and Community Income Eligibility Requirements
Section 13: Results Oriented Management and Accountability (ROMA) System
Section 14: CSBG Programmatic Assurances and Information Narrative
Section 15: Federal Certifications
Attachments
Attachment 1: Delegation of Authority
Attachment 2: Change Matrix (Placeholder)
Attachment 3: Allocations
Attachment 3B: Funding Formula
Attachment 4: Sections 9 and 14 Service Delivery System and Program Narratives (overflow text)
Attachment 5: Arizona Administrative Code Title 6, Chapter 13 (Regarding STCS)
Attachment 6: Request for Application (RFA) Placeholder
Attachment 7: Scope of Work (SOW)
Attachment 8: DES Single Audit Policy
Attachment 9: Su recipient Monitoring Policy
Attachment 10: Income Thresholds for State Fiscal Year 2017.
Attachment 11: Network and Public Comments

SECTION 1
CSBG Lead Agency, CSBG Authorized Official, CSBG Point of Contact, and Official State
Designation Letter
1.1. Provide the following information in relation to the lead agency designated to administer CSBG
in the State, as required by Section 676(a) of the CSBG Act. The following information should
mirror the information provided on the Application for Federal Assistance, SF-424M.
1.1a. Lead agency
The Arizona Department of Economic Security (DES) is the designated State agency responsible for the
administration of the CSBG as identified by the Governor. All activities of DES are the responsibility of the
Director. Primary responsibility for CSBG program planning, development, contracting, reporting, and
monitoring is delegated to the Division of Aging and Adult Services (DAAS), Community Action Programs
and Services (CAPS), referred to going forward as DAAS/CAPS. DAAS/CAPS contracts directly with
Community Action Agencies (CAAs), one migrant organization, and the Arizona Community Action
Association. Some of these agencies subcontract with other community agencies within their service
delivery area. For example, in Maricopa County, there are CAAs in each of the major cities in the service
area. CAAs are also referred to in this document as eligible entities.
1.1b. Cabinet or administrative department of this lead agency
 Community Services Department
 Human Services Department
 Social Services Department
 Governor’s Office
 Community Affairs Department
 Other, describe:
1.1c. Division, bureau, or office of the CSBG authorized official : DES Division of Aging and
Adult Services (DAAS), Community Services Administration (CSA)
1.1d. Authorized official of the lead agency: Henry Darwin, Interim Director, DES
1.1e. Street address: 1789 West Jefferson St.
1.1f. City: Phoenix
1.1g. State: AZ
1.1h. Zip: 85007
1.1i. Telephone number and extension: (602)542-5757
1.1j. Fax number: 602-542-5339

1.1k. Email address: director@azdes.gov
1.1l. Lead agency website: https://des.az.gov/
1.2. Provide the following information in relation to the designated State CSBG point of contact.
1.2a. Agency name: Arizona Department of Economic Security, Division of Aging and Adult
Services, Community Services Administration
1.2b. Name of the point of contact: Tamberly Frazee, Arizona Department of Economic
Security, Division of Aging and Adult Services
1.2c. Street address: 1789 W. Jefferson St., Site Code 950A
1.2d. City: Phoenix

1.2e. State: AZ
1.2f. Zip 85007
1.2g. Point of contact telephone number: 602-542-2895
1.2h. Fax number: 602-542-6655
1.2i. Point of contact email address: tfrazee@axdes.gov
1.2j. Point of contact agency website: https://des.az.gov/
1.3. Designation Letter: Attach the State’s official CSBG designation letter. If either the governor or
designated agency has changed, update the letter accordingly:
►Attachment 1 – Designation of Authority Attachments\Attachment 1 DELEGATION OF AUTHORITY
GOVERNOR.pdf

SECTION 2
State Legislation and Regulation
2.1. CSBG State Legislation: Does the State have a statute authorizing CSBG?  Yes  No
2.2. CSBG State Regulation: Does the State have regulations for CSBG?  Yes  No
2.3. If yes was selected in item 2.1 or 2.2, attach a copy (or copies) of legislation and/or regulations
or provide a hyperlink(s), as appropriate
2.4. State Authority: Select a response for each question about the State statute and/or regulations
authorizing CSBG:
2.4a. Did the State legislature enact authorizing legislation, or amendments to an existing
authorizing statute, last year?  Yes  No
2.4b. Did the State establish or amend regulations for CSBG last year?  Yes  No
2.4c. Does the State statutory or regulatory authority designate the bureau, division, or office
in the State government that is to be the State administering agency?  Yes  No

SECTION 3
State Plan Development and Statewide Goals
3.1. CSBG Lead Agency Mission and Responsibilities: Briefly describe the mission and
responsibilities of the State agency that serves as the CSBG lead agency.
DES came under new administration in 2015 under newly elected Governor Douglas A. Ducey and the
newly appointed Director of DES, Timothy Jeffries.
The Arizona Department of Economic Security (DES) is the designated State agency responsible for the
administration of the CSBG as identified by the Governor. All activities of DES are the responsibility of the
Director. Primary responsibility for CSBG program planning, development, contracting, reporting, and
monitoring is delegated to the Division of Aging and Adult Services (DAAS), Community Services
Administration.
The agency mission statement was revised in Federal Fiscal Year (FFY) 2015 to read as follows: “The
Arizona Department of Economic Security makes Arizona stronger by helping Arizonans reach their
potential through temporary assistance for those in need, and care for the vulnerable.”
DES administers the Unemployment Insurance (UI), Workforce Innovation and Opportunity (WIOA) Act
programs, and the Supplemental Nutrition Assistance (SNAP) programs. The Agency also provides child
support enforcement services and comprehensive programs to assist persons with developmental
disabilities. The Division of Aging and Adult Services (DAAS) administers the Community Action Program,
the State Adult Protective Services program, Refugee Resettlement Program, Independent Living Support
Services (for seniors and persons with disabilities), Aging and Disability Services, State Homeless Program,
Low Income Home Energy Assistance (LIHEAP), Hunger Prevention Programs and Domestic Violence
Programs.
DES Values:
-Teamwork – We collaborate with humility, and partner with kindness
-Respect – We appreciate each other, and value those we serve
-Integrity – We never lie, cheat, steal, bully or harass – nor tolerate those who do
-Accountability – We commit to excellence, innovation and transparency
-Diversity – We respect all Arizonans, and honor those in need
DES Vision:
-Opportunity, assistance and care for Arizonans in need
DES Goals:
--Serve Arizonans with integrity, humility, and kindness
Support Arizonans to reach their potential through social services that train, rehabilitate, and connect
them with job creators
-Provide temporary assistance to Arizonans in need while they work toward greater self-sufficiency
-Provide children with food, health care, and parental financial support; provide services to individuals

with disabilities; and protect the vulnerable by investigating allegations of abuse, neglect, and
exploitation.

3.2. State Plan Goals: Describe the State’s CSBG-specific goals for State administration of CSBG under
this State Plan.
(a) DAAS/CAPS coordinates with the Arizona Community Action Association to provide training and
technical assistance using State CSBG discretionary dollars, providing training and technical
assistance to those entities in need of such assistance and such activities will not be considered
administrative expenses;
(b) coordinating state-operated programs and services targeted to low-income individuals, and families
with children, and at the option of the State, locally operated programs, and services, targeted to
low-income individuals and families with children, with services provided by eligible entities and
other organizations funded under the CSBG Act, including out-posting appropriate state or local
public employees into entities funded to ensure increased access to services provided by such state
or local entities;
(c) supporting statewide coordination and communication among eligible entities; a portion of CSBG
discretionary funds will be targeted to support statewide coordination and communication among
eligible entities on a yearly basis that will be accomplished through support of the Community
Action Agencies and the Arizona Community Action Association;
(d) analyzing the distribution of funds made available under the CSBG Act, to determine if such funds
have been targeted to the areas of greatest need. The State utilizes a funding distribution formula
that analyzes local rates of poverty and unemployment, accounts for rural factors and tribal
populations, and makes an adjustment for a limited purpose entity that serves migrant and seasonal
farmworkers. The State also uses a minimum funding variable in the distribution formula that
allows entities with smaller populations to receive at least $150,000;
(e) supporting asset-building programs for low-income individuals, such as programs supporting
Individual Development Accounts (IDAs);
(f) supporting innovative programs and activities conducted by eligible entities or other neighborhood-
based organizations to eliminate poverty, promote self-sufficiency, and promote community
revitalization; and
(h) supporting other activities, consistent with the purposes of the CSBG Act.
For this amendment: DAAS/CAPS, in response to Network input, and in coordination with the Network,
will utilize SFY 2018 to further develop statewide goals for Community Action, and will rewrite this
planning section for the FFYs 2019-2020 CSBG State Plan
3.3. State Plan Development: Indicate the information and input the State accessed to develop this
State Plan.
3.3a. Analysis of
 State Performance Indicators and/or National Performance Indicators (NPIs)
 U.S. Census data

 State performance management data (e.g., accountability measures, ACSI survey
information, and/or other information from annual reports)
 Other data (describe)
 Eligible entity community needs assessments
 Eligible entity plans
 Other information from eligible entities, e.g., State required reports (describe)
Poverty and rural: current U.S. Decennial Census data available and updated annually using the ACS 5-
year Survey. Employment statistics obtained from current Local Area Unemployment Survey (LAUS).
Program narratives, public hearing comments and solicited feedback from eligible entities.
For this amendment, the following revised funding factors and data sources for the CSBG funding
distribution formula are as follows:
Attachment 3A FFY 2018 Funding Formula.docx►In Attachment 3a, Funding Formula Commented [DAAS1]: Needs to be updated to align
with current discussions and decisions.
3.3b. Consultation with Commented [GDL2R1]: The final disposition of the
funding formula will be set forth in the attachment.
 Eligible entities (e.g., meetings, conferences, webinars; not including the public That’s what needs updating.
hearing)
 State community action association and regional CSBG T & TA providers
 State partners and/or stakeholders (describe)
 National organizations (describe)
 Other (describe)
.
3.4. Eligible Entity Involvement
3.4a. Describe the specific steps the State took in developing the State Plan to involve the
eligible entities.
DAAS/CAPS informed the Community Action Network (the Network) in February 2016 about the new
Model State Plan format for FFYs 2017-2018. DAAS/CAPS circulated within the Network draft State Plan
proposed changes in late March 2016, and requested comments in mid-April 2016. In response to the
Network comments and subsequent discussion with the group, additional changes were made. See
Attachment 2 CSBG St Plan Change Matrix 2017.
For this amendment: DAAS/CAPS distributed a matrix of proposed changes and updates for the FFY 2018
amendment to the Network in November 2016 and solicited input. A draft amendment for Network comment
was distributed in February 2017, for comment. Following meetings and discussion, DAAS/CAPS
published the draft amendment for public inspection to its website in May 2017, and conducted one public
hearing in June [ ], 2017. DAAS/CAPS also conducted a legislative hearing in August, 2017.
3.4b. Performance Management Adjustment: How has the State adjusted State Plan
development procedures under this State Plan, as compared to past plans, in order 1) to
encourage eligible entity participation and 2) to ensure the State Plan reflects input
from eligible entities? Any adjustment should be based on the State’s analysis of past
performance in these areas, and should consider feedback from eligible entities, OCS,

and other sources, such as the public hearing. If the State is not making any
adjustments, provide further detail
In SFY 2015, the development year of the FFY 2015-2016 State Plan, DAAS/CAPS scheduled three public
hearings, two outside of the Phoenix metropolitan area, in response to feedback from the Network,
indicating a desire for broader public availability to review and provide public testimony. Also in SFY
2015, DAAS/CAPS shortened its development time period to provide more time for public review of the
State Plan draft document prior to public hearings. DAAS/CAPS has created a scheduled process for
development of the two-year Plan that includes scheduled meetings with the Network and opportunities for
comment and discussion prior to posting the State Plan draft for formal public review.
For this amendment, DAAS/CAPS has revised this two-year plan for FFY 2018. DAAS/CAPS has, in
consultation with the Network, reviewed funding formula factors for CSBG, and sought input from the
Network to update funding distribution, strengthen narrative sections, update and clarify monitoring
activities and revise CSBG Organizational Standards implementation policy. in SFY 2017, DAAS/CAPS
began discussions with the network earlier in the grant cycle, and offered additional time for input and
inspection. Section 3.5 below was revised to reflect guidance from OCS and NASCSP regarding expectations
for growth in this score.
3.5. Eligible Entity Overall Satisfaction: Provide the State’s target for eligible entity Overall
Satisfaction during the performance period: 67

SECTION 4
CSBG Hearing Requirements
4.1. Public Inspection: Describe how the State made this State Plan, or revision(s) to the State
Plan, available for public inspection, as required under Section 676(e)(2) of the Act.
The FFYs 2017-2018 CSBG State Plan was made available for public inspection and comment via
publication and the public hearing process in 2016. Paper copies of the State Plan are available upon
request. The draft State Plan was posted on the DES website in June 2016. Oral and written testimony were
solicited and accepted via the DES website and at public hearings from June 6, 2016 through July 11, 2016.
For this amendment: For FFY 2018, the amended FFYs CSBG State Plan was posted on the DES website
on May [ ], 2017
4.2. Public Notice/Hearing: Describe how the State ensured there was sufficient time and
statewide distribution of notice of the public hearing(s) to allow the public to comment on
the State Plan, as required under 676(a)(2)(B) of the CSBG Act.
FFYs 2017-2018 - DAAS/CAPS conducts multiple public hearings throughout the State in conjunction with
the development of the biennial State Plan. DAAS/CAPS also conducts a single public hearing in Phoenix
in the intervening years, to solicit public comment regarding amendments to the current Plan. DAAS/CAPS
will post a public notice, via its website, of the hearing schedule at least 30 days prior to any public
hearing(s). The Department conducted several public hearings in 2016 to ensure public inspection,
facilitate review, and solicit comments regarding the FFY 2017-2018 CSBG State Plan, and to provide
opportunities for the public in various parts of the State to offer comments without the necessity of traveling
to Phoenix. The first public hearing was held in Phoenix on July 5, 2016; the second in Tucson (southern
Arizona) on July 6 2016; and the third in Flagstaff (northern Arizona) on July 7, 2016. In the intervening
year, 2017, DAAS/CAPS will conduct one public hearing in Phoenix in May or June, to ensure public
inspection and review of amendments to the FFYs 2017-2018 CSBG State Plan. For this amendment: in the
intervening plan year, 2017, DAAS/CAPS conducted one public hearing in Phoenix in June, to ensure public
inspection and review of amendments to the FFYs 2017-2018 CSBG State Plan.
4.3. Public and Legislative Hearings: Specify the date(s) and location(s) of the public and
legislative hearing(s) held by the designated lead agency for this State Plan, as required under
Section
676(a)(2)(B) and Section 676(a)(3) of the Act. (If the State has not held a public hearing in
the prior fiscal year and/or a legislative hearing in the last three years, provide further
detail).
Legislative hearings are held once every three years in accordance with Section 676(a)(3) of the Act. The
last legislative hearing was held on August 6, 2014. For this amendment: DAAS/CAPS held a legislative
hearing on August [ ], 2017.

Date Location Type of Hearing Commented [GDL3]: OCS has requested we include
full addresses for the location of hearings.
August [ ], 2017 Arizona State House of Representatives Chamber, Arizona State • Legislative
Capitol,
1700 West Washington Street
Phoenix, AZ 85007
• Public
July [ ], 2017
Arizona State Capitol, Executive Tower [TBD] •
Grand Canyon Room, 11:00 am,
•
1700 West Washington Street, Suite 200 •
Phoenix, AZ 85007 •
•
July 5, 2016 Arizona State Capitol, Executive Tower • Public
Grand Canyon Room, 11:00 am,
1700 West Washington Street, Suite 200
Phoenix, AZ 85007
Tucson, Arizona
July 6, 2016 [address] • Public
Flagstaff, Arizona
July 7, 2016 [address] • Public
ADD a ROW function Note: rows will be able to be added for each additional hearing
4.4. Attach supporting documentation or a hyperlink for the public and legislative hearings.
For this amendment: The last legislative hearing was held on August [ ], 2017. Public notice and public
hearing documentation is attached.
►[ATTACHED 2017 PUBLIC HEARING NOTICE AND COMMENTS HERE]
[add link to hearing video when available]
End of Section 4

SECTION 5
CSBG Eligible Entities
5.1. CSBG Eligible Entities: In the table below, list each eligible entity in the State, and indicate
public or private, the type(s) of entity, and the geographical area served by the entity. (This
table should include every CSBG Eligible Entity to which the State plans to allocate 90 percent
funds, as indicated in the table in item 7.2. 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.)
Geographical Area Brief
CSBG Eligible Public or Type of Entity
Served by county Description of
Entity Nonprofit (choose all that apply)
(Provide all counties) “Other”
City of Glendale Public Local Government Agency City of Glendale
Community Action (Maricopa County)
Program
City of Phoenix Public Local Government Agency City of Phoenix
Human Services (Maricopa County)
Department
Coconino County Public Local Government Agency Coconino County
Community Services
Department
Community Action Private Community Action Agency Pinal County
Human Resources
Agency
Gila County Public Local Government Agency Gila County
Community Action
Agency
Maricopa County Public Local Government Agency Balance of
Human Services Maricopa County
Department
Mesa Community Private Community Action Agency City of Mesa
Action Network (Maricopa County)
Northern Arizona Public Other Yavapai, Navajo, Quasi-
Council of and Apache Governmental
Governments Counties Agency/
Association of
Governments
Pima County Public Local Government Agency Pima County
Community Action
Agency
Southeastern Private Community Action Agency Greenlee, Graham,
Arizona Community Cochise, and Santa
Action Program Cruz Counties

Western Arizona Public Other Mohave, Yuma and Quasi-
Council of La Paz Counties Governmental
Governments Agency/
Association of
Governments
Portable, Practical, Private Migrant or Seasonal Statewide *With limited
Educational Farmworker Organization purpose
Preparation, Inc.*
ADD A ROW function Note: rows will be able to be added for each eligible entity funded in the State
5.2. Total number of CSBG eligible entities: 12
5.3. Changes to Eligible Entities List: Has the list of eligible entities under item 5.1 changed since
the State’s last State Plan submission? If yes, briefly describe the changes.  Yes  No
End of Section 5

SECTION 6
Organizational Standards for Eligible Entities
6.1. Choice of Standards: Check the box that applies. If using alternative standards, a) attach the
complete list of alternative organizational standards, b) describe the reasons for using
alternative standards, and c) describe how the standards are at least as rigorous as the COE-
developed standards.
 The State will use the CSBG Organizational Standards Center of Excellence (COE)
organizational standards (as described in IM 138)
 The State will use an alternative set of organizational standards
6.2. If the State is using the COE-developed organizational standards, does the State propose
making a minor modification to the standards, as described in IM 138?  Yes  No
6.2a. If yes was selected in item 6.2, describe the State’s proposed minor modification to the
COE-developed organizational standards, and provide a rationale. N/A
6.3. How will/has the State officially adopt(ed) organizational standards for eligible entities in the
State in a manner consistent with the State’s administrative procedures act? If “Other” is
selected, provide a timeline and additional information, as necessary.
 Regulation
 Policy
 Contracts with eligible entities
 Other, describe: [Narrative, 2500 Characters]
For this amendment: Through discussion with the Network in SFY 2017, DAAS/CAPS agreed that a
written policy clarification will need to be developed a policy to facilitate implementation and assess
ongoing compliance with the Standards going forward. This item will be amended for FFY 2018 to Commented [DAAS4]: We have a policy draft that
reflect enhancements. DAAS/CAPS engaged a third party consultant to evaluate the State Office we need to finish. We should work with Jutta on timing.
With that policy, we should indicate here that a policy
processes, and the assessments. was developed?
Commented [GDL5R4]: We project items in the draft
6.4. How will the State assess eligible entities against organizational standards, as described in IM that are anticipated to be complete by the submission
138? date, casting them in past tense, so yes. I’m also adding
the bit about bringing in a consultant.
 Peer-to-peer review (with validation by the State or State-authorized third party)
 Self-assessment (with validation by the State or State-authorized third party)
 Self-assessment/peer review with State risk analysis
 State-authorized third party validation
 Regular, on-site CSBG monitoring
 Other
6.4a. Describe the assessment process.
► See attachment –[#] DRAFT - Implementation of Standards -6.4.docx Commented [DAAS6]: Some comments on the policy
are in document. Need to review as I wanted to focus
on the plan in this review.

6.5. Will the State make exceptions in applying the organizational standards for any eligible entities
due to special circumstances or organizational characteristics, as described in IM 138?
 Yes  No
Standard 8.5: A non-profit eligible entity that is a smaller “agency within an agency” whose tripartite
board does not have the authority to procure accounting services, and whose CSBG allocations do not
exceed the minimum funding variable of $150,000, will not be bound by the Standard requirement to have
“solicited bids for its audit within the past 5 years.” See IM 138. At the discretion of the State, Standard
8.5, as written for public agencies, shall apply to such non-profit agencies. The State will require
justification from agencies that take this position, and will approve such an exemption only if it is
determined by the State that this activity is out of the purview of the agency Tripartite Board, and agency
allocations do not exceed the funding allocation indicated above.
6.5a. If yes was selected in item 6.5, list the specific eligible entities the State will exempt from
meeting organizational standards, and provide a description and a justification for each
exemption.
Portable Practical Education Preparation – Standard 8.5: Agency receives approximately $100,000 in
CSBG funding per SFY to support programs funded by over $2,000,000 million in federal, local, and private
funds. This agency has an annual budget of nearly $24,000,000. The agency Tripartite Board operates
under the authority of a larger governing board and only has authority over CSBG and other leveraged
funds under its Community Action program. CSBG funds are not used to pay for the services of the agency’s
accounting firm and the Board does not have the authority to approve the selection of an agency-wide
auditor.
6.6. Performance Target: What percentage of eligible entities in the State does the State expect will
meet all the State-adopted organizational standards in the next year?
75% Commented [DAAS7]: Is this just a place holder as I
- End of Section 6 think we should be able to identify a percentage or is it
100%.
Commented [GDL8R7]: This measure is a topic of
controversy nationally too, and may be revised. The
current plan says 75%. Note: there is no space for
narrative here.

SECTION 7
State Use of Funds
Eligible Entity Allocation (90 Percent Funds) [Section 675C(a) of the CSBG Act]
7.1 Formula: Select the method (formula) that best describes the current practice for allocating
CSBG funds to eligible entities.
 Historic
 Base + Formula
 Formula Alone
 Formula with Variables
 Hold Harmless + Formula
 Other
7.1a. Does the State statutory or regulatory authority specify the terms or formula for
allocating the 90 percent funds among eligible entities?  Yes No
►
7.2. Planned Allocation: Specify the planned allocation of 90 percent funds to eligible entities, as
described under Section 675C(a) of the CSBG Act. The estimated allocations may be in
dollars or percentages. For each eligible entity receiving funds, provide the Funding Amount
in either dollars (columns 2 and 4) or percentage (columns 3 and 5) for the fiscal years
covered by this plan.
►See Attachment 3A Attachment 3A FFY 2018 Funding Formula.docx
For this amendment: TBD
Planned CSBG 90 Percent Funds
Year One Year Two
CSBG Eligible
Funding Amount Funding Amount Funding Amount Funding Amount
Entity
$ % $ %
City of Glendale
Community Action $ 190,479 TBD
Program
City of Phoenix Human $ 1,286,962
Services Department
Coconino County
Community Services $ 150,000
Department
Community Action Human $ 272,403
Resources Agency
Gila County Community $ 150,000
Action Agency
Maricopa County Human $ 811,075
Services Department
Mesa Community Action $ 294,411
Network
Northern Arizona Council $ 235,376
of Governments
Pima County Community $ 692,289
Action Agency

Southeastern Arizona
Community Action $ 208,297
Program
Western Arizona Council $ 471,007
of Governments
Portable, Practical,
Educational Preparation, $ 97,190 $ 97,190
Inc.
Total Totals will be auto-populated Totals will be auto-populated
7.3. Distribution Process: Describe the specific steps in the State’s process for distributing 90
percent funds to the eligible entities and include the number of days each step is expected
to take; include information about State legislative approval or other types of
administrative approval (such as approval by a board or commission).
The State operates the Community Action Program on the State Fiscal Year (SFY), July 1st through
June 30th. The State enters into five-year budget-based/cost reimbursement contracts with eligible
entities. Upon notification from OCS of annual allocations allotment to states. from OCS, DAAS/CAPS
communicates estimated annual allocations to eligible entities for the upcoming SFY to eligible entities
in February, March or no later than April prior to the beginning of the upcoming SFY. DAAS/CAPS
calls these communications ALERTS. Following any subsequent federal allocation change, OCS
Notices of Award, etc., dollars are announced each quarter as they occur. The award of carryover from
the previous year is also announced in August of the current fiscal year. If contract dollar amounts are
changed, DAAS/CAPS amends the contract to reflect funding changes.
For this Amendment: This change of data source had a significant impact on the distribution of funding
for CSBG and other federal funds. DAAS/CAPS held the eligible entities harmless from these distribution
changes while a solution could be agreed upon. Responding to input from the Network, DAAS/CAPS, in
consultation with a third party consultant, conducted research and negotiations with the Network in SFY
2017 to redesign the funding formula to ensure the fairest possible distribution of funds. Funding factors
agreed upon by the Network and DAAS/CAPS will be implemented for SFY 2018 for the 90 percent of CSBG
funds distributed to the eligible entities. See the attached document for the new funding formula.
►See Attachment [#], Funding Distribution Formula]Attachment 3A FFY 2018 Funding
Formula.docx
7.4. Distribution Timeframe: Does the State plan to make funds available to eligible entities no
later than 30 calendar days after OCS distributes the Federal award?  Yes No
7.4a. If no, describe State procedures to ensure funds are made available to eligible entities
consistently and without interruption.
For this amendment: The State operates on a State Fiscal Year. Funds allocated to eligible entities are
made available for obligation on the first day of the State Fiscal Year. Funds are disbursed on a cost
reimbursement basis. Eligible entities annually submit a proposed Itemized Service Budget (ISB) document,
for detailing allowable expenditures for activities included in the agency’s CAP Plan. Eligible entities
invoice the State on a monthly basis for these allowable expenditures under CSBG. Invoices are due on the

25th of each month. Larger public entities may be allowed to invoice semi-monthly upon DAAS/CAPS
approval. Invoices must include backup documentation for expenditures billed. DAAS/CAPS is bound by
contract with the eligible entities to make payments on approved invoices within 30 days.
Payments on invoices may be delayed temporarily pending the submission of past-due contract
deliverables, such as Community Action Plan documents or required reports, or for incomplete
documentation.
7.5. Performance Management Adjustment: How is the State improving grant and/or contract
administration procedures under this State Plan as compared to past plans? Any improvements
should be based on analysis of past performance, and should consider feedback from eligible
entities, OCS, and other sources, such as the public hearing. If the State is not making any
improvements, provide further detail.
The State is currently participating in Government Transformation with a focus on implementing lean
initiatives to dramatically shorten the time for developing Requests for Applications (RFAs). Once
implemented, a shorter timeframe will benefit eligible entities by communicating contract changes sooner
and reduce State administrative costs. In SFY 2016, DAAS/CAPS and the Network initiated a workgroup
project to evaluate the funding distribution formula factors. In SFY 2017, DAAS/CAPS engaged a
consultant to conduct research and report to the group best practices utilized by other states, and additional
data sources that may be of use in an updated formula.
Administrative Funds [Section 675C(b)(2) of the CSBG Act]
7.6. What amount of State CSBG funds does the State plan to allocate for administrative activities,
under this State Plan? The estimate may be in dollars or a percentage: 5%
7.7. How many State staff positions will be funded in whole or in part with CSBG funds under this
State Plan? [8] Commented [GDL9]: This will be updated following
completion of the annual report.
7.8. How many State Full Time Equivalents (FTEs) will be funded with CSBG funds under this State
Plan? [1.78] Commented [GDL10]: This phrase will be updated
following the annual report.
Remainder/Discretionary Funds [Section 675C(b) of the CSBG Act]
7.9. Does the State have remainder/discretionary funds?  Yes  No
If yes was selected, describe how the State plans to use remainder/discretionary funds in the
table below.
Use of Remainder/Discretionary Funds
a. Training/technical assistance to eligible [Not Fillable] These planned
entities $ 100,000 $ 100,000 services/activities will be described in
State Plan item 8.1
[Optional Narrative, 2500 characters]
b. Coordination of State-operated programs These planned services/activities will
and/or local programs be described in State Plan section 9,
State Linkages and Communication.

Use of Remainder/Discretionary Funds
[Optional Narrative, 2500 characters]
c. Statewide coordination and These planned services/activities will
$ 55,000 $ 55,000
communication among eligible entities be described in State Plan section 9,
State Linkages and Communication.
d. Analysis of distribution of CSBG funds to
[Narrative, 2500 Characters]
determine if targeting greatest need
e. Asset-building programs [Narrative, 2500 Characters]
Projects – Attachment 3, Allocations
2017. Special Projects funds that are
unallocated may be utilized for
emergencies and disasters during the
plan year. Eligible entities that
received Special Projects funds may
f. Innovative programs/ activities by eligible $ 88,820 $ 88,820 make carryover requests for ongoing
entities or other neighborhood groups projects. Such requests will be
approved at the discretion of the
State. Unobligated funds will be
carried over to the next grant year,
and redistributed with the 90 percent
funds allocated to eligible entities.
g. State Charity Tax Credits
Emergencies
See Attachment 3 Allocations 2017.
Unobligated funds from the current
plan year will be carried over to the
h. Other Activities 30,000 $30,000
next grant year, and redistributed
with the 90 percent funds allocated to
eligible entities.
Totals Auto- Auto- Auto- Auto- [$ 273,820]
Calculated Calculated Calculated Calculated
►Attachment: Narrative regarding allocations Attachment 3 Allocations 2018.docx

7.10. What types of organizations, if any, does the State plan to work with (by grant or contract using
remainder/discretionary funds) to carry out some or all of the activities in table 7.9.
 CSBG eligible entities (if checked, include the expected number of CSBG eligible entities to
receive funds) [Narrative, 2500 Characters]
 Other community-based organizations
 State Community Action association
 Regional CSBG technical assistance provider(s)
 National technical assistance provider(s)
 Individual consultant(s)
 Tribes and Tribal Organizations
 Other [Narrative, 2500 Characters]
 None (the State will carry out activities directly)
7.11. Performance Management Adjustment: How is the State adjusting the use of
remainder/discretionary funds under this State Plan as compared to past plans? Any
adjustment should be based on the State’s analysis of past performance, and should consider
feedback from eligible entities, OCS, and other sources, such as the public hearing. If the
State is not making any adjustments, provide further detail.
DAAS/CAPS will work with the Community Action Network to evaluate discretionary funding
priorities in SFY 2017 and to develop a response for the FFY 2018 Amendment. See
Attachment 3 Allocations 2018 for detail on CSBG Discretionary Funding activities.
►Attachment 3 Allocations 2018.docx
End of Section 7 –

SECTION 8
State Training and Technical Assistance
8.1. Describe the State’s plan for delivering CSBG-funded training and technical assistance to eligible
entities under this State Plan by completing the table below. Add a row for each activity: indicate
the timeframe; whether it is training, technical assistance or both; and the topic. (CSBG funding
used for this activity is referenced under item 7.9(a), Use of remainder/discretionary Funds.)
For this amendment: TBD
Training and Technical Assistance
Fiscal Year (FY) Quarter Training, Technical
Topic Brief Description of “Other”
(Q) / Timeframe Assistance, or Both
FY1 - Q1 Training Fiscal
FY1 - Q1 Technical Assistance Monitoring
FY1 - Q3 Both Other Conference to include but
Training and Technical Assistance
Fiscal Year (FY) Quarter Training, Technical
Topic Brief Description of “Other”
(Q) / Timeframe Assistance, or Both
T/TA
FY1 - Q4 Training ROMA
38T 38T 38T
State Response Training and Technical Assistance TBD
FY1 - Q1 Technical Assistance Organizational Standards -
General
FY1 - Q1 Technical Assistance Strategic Planning
FY1 - Q2 Technical Assistance Monitoring - General
FY1 - Q2 Training ROMA
FY1 - Q2 Technical Assistance Monitoring
FY1 - Q3 Training Governance/Tripartite Boards
FY1 - Q2 Technical Assistance Reporting
FY1 - Q4 Training Strategic Planning
FY2 - Q1 Training ROMA Evaluation
FY2 - Q1 Training Governance/Tripartite Boards
FY1 - Q1 Technical Assistance Reporting
FY1 - Q1 Technical Assistance Other State Policies
FY2 - Q2 Training Other State Policies
FY2 - Q2 Training Organizational Standards -
General
Fy – Q1 Training Other Case Management
FY1 - Q4 Training Monitoring
Choose an item. Choose an item. Choose an item.

Comment:
DAAS/CAPS will work closely with the Arizona Community Action Association in consultation with the
Network, to develop a training and technical assistance (T/TA) strategy that will outline the various T/TA
activities to be conducted, including but not limited to, the following:
-Tripartite boards, such as new member orientation and low-income representative recruitment;
-ROMA training for agency staff and board members with respect to goal setting and evaluation of
outcomes; and
-basics of preparing the annual CSBG Information System Survey/ and the new CSBG Annual Report as
the new system and technical assistance becomes available;
-Training on ROMA Next Generation
-Organizational Standards
Strategic Planning
CAP Plans
Bylaws
The State will investigate options in conjunction with the Network, to develop further training and technical
assistance priorities for implementation in SFY 2018. This schedule will be adjusted based on the
availability of agency staff, boards and trainers. In addition, DAAS/CAPS will do the following:
1. To summarize trends from the monitoring visits and assessments; and identify significant
deficiencies common in the Network.
2. Provide TTA during visits or calls on documentation, especially regarding board action and board
engagement; what documentation does the State require CAAs to have prepared for monitoring
visits.
8.1a. The planned budget for the training and technical assistance plan (as indicated in the
remainder/discretionary funds table in item 7.9): [$100,000]
8.2. Does the State have in place Technical Assistance Plans (TAPs) or Quality Improvement Plans
(QIPs) for all eligible entities with unmet organizational standards, if appropriate? Yes  No
For This amendment:
DAAS/CAPS will place formal TAPs in place for agencies with unmet organizational standards beginning
in SFY 2018. For agencies with unmet standards, DAAS/CAPS will either provide training and technical
assistance with its own forces or through the Arizona Community Action Association which is provided
CSBG discretionary funds for this purpose. to facilitate agencies implementing and attaining compliance.
DAAS will track unmet standards, needed documentation, time-bound objectives toward compliance via
the DAAS Contracts Report of Findings (ROF) document. DAAS/CAPS will use this document to provide
a summary of the State assessment. Standards that are unmet, or met but needing documentation, or
currently implementing, will be listed as Recommendations, and summarized with requested actions and
due dates. See Attachment 6.4. for additional details
8.3. Indicate the types of organizations through which the State plans to provide training and/or
technical assistance as described in item 8.1, and briefly describe their involvement? (Check all
that apply.)
 CSBG eligible entities (if checked, provide the expected number of CSBG eligible entities to

receive funds)
 Other community-based organizations
 State Community Action association
 Regional CSBG technical assistance provider(s)
 National technical assistance provider(s)
 Individual consultant(s)
 Tribes and Tribal Organizations
 Other
DAAS/CAPS will work closely with the Arizona Community Action Association in consultation with the
Network, to develop a training and technical assistance (T/TA) strategy that will outline the various T/TA
activities to be conducted including, but not limited to, the following:
• Tripartite boards, such as new member orientation and low-income representative recruitment;
• ROMA training for agency staff and board members with respect to goal setting and evaluation of
outcomes; and
• basics of preparing the annual CSBG Information System Survey/ and the new CSBG Annual Report
as the new system and technical assistance becomes available;
• Training on ROMA Next Generation
8.4. Performance Management Adjustment: How is the State adjusting the training and technical
assistance plan under this State Plan as compared to past plans? Any adjustment should be
based on the State’s analysis of past performance, and should consider feedback from eligible
entities, OCS, and other sources, such as the public hearing. If the State is not making any
adjustments, provide further detail.
For this amendment: The State will investigate options in conjunction with the Network and the ACAA, to
develop further training and technical assistance priorities for implementation in SFY 2018 and 2019. This
schedule will be adjusted based on the availability of agency staff, boards and trainers. The FFY 2018
amendment will reflect any changes. DAAS/CAPS will also engage a consultant to assist in the
implementation and evaluation of our processes and evaluate State assessments of compliance with CSBG
Organizational Standards. Commented [GDL11]: Added some text here.
End of Section 8 –

SECTION 9
State Linkages and Communication
9.1. State Linkages and Coordination at the State Level: Describe the linkages and coordination at
the State level that the State plans to create or maintain to ensure increased access to CSBG
services to low-income people and communities under this State Plan and avoid duplication of
services (as required by the assurance under Section 676(b)(5)). Describe or attach additional
information as needed.
 State Low Income Home Energy Assistance Program (LIHEAP) office
 State Weatherization office
 State Temporary Assistance for Needy Families (TANF) office
 State Head Start office
 State public health office
 State education department
 State Workforce Innovation and Opportunity Act (WIOA) agency
 State budget office
 Supplemental Nutrition Assistance Program (SNAP)
 State child welfare office
 State housing office
 Other
9.2 – Revisit - bookmark
9.2. State Linkages and Coordination at the Local Level: Describe the linkages and coordination at
the local level that the State plans to create or maintain with governmental and other social
services, especially antipoverty programs, to assure the effective delivery of and coordination
of CSBG services to low-income people and communities and avoid duplication of services (as
required by assurances under Sections 676(b)(5) and (b)(6)). Attach additional information as
needed.
Linkage programs may include family/individual counseling, transportation, programs for persons
with disabilities and seniors, neighborhood activities, food and nutrition, information and referral,
local needs assessments, community outreach summer recreation, and other miscellaneous projects
involving formal and informal partnerships and organizational relationships in the community.
DAAS/CAPS has initiated conversations with the State WIOA Office, which is housed in a separate
division of DES, regarding enhancing coordination of workforce related activities at the State level.
DAAS/CAPS seeks specifically to work with the WIOA State Office to share data to facilitate more
robust outcome reporting. The newly implemented DES Office of Community Engagement is also
conducting information sessions and coordination among agency divisions and private community
organizations such as Valley of the Sun United Way to promote statewide communication and to
develop linkages between and among the various State agency divisions and charitable
organizations, including faith-based organizations in the community. The State CSBG program
staff actively participate in this initiative. DAAS/CAPS will further develop narrative descriptions
of these activities in the State Plan amendment for FFY 2018. For this Amendment: “DAAS/CAPS

will continue its conversations with the State Offices of WIOA and Child Support Services in SFY Commented [DAAS12]: Let’s chat to see if we can
2018 to strengthen partnerships and collaborations with the CAAs. DAAS/CAPS will investigate strengthen this section as the WIOA work can be
revisited, but I have also connected several CAAs with
opportunities to coordinate and/or exchange information with the State offices of Head Start their local DCSS office. Maybe remove the OCE
(Education Department), Public Health, and Child Welfare. .” language.
DAAS/CAPS will further develop narrative descriptions of these activities in the State Plan for Commented [GDL13R12]: See also, 9.4b.
FFY 2019.
9.3. Eligible Entity Linkages and Coordination
9.3a State Assurance of Eligible Entity Linkages and Coordination: Describe how the State
will assure that the eligible entities will coordinate and establish linkages to assure the
effective delivery of and coordination of CSBG services to low-income people and
communities and avoid duplication of services (as required by the assurance under
Section 676(b)(5)). Attach additional information as needed.
Eligible entities are required to submit to DAAS/CAPS a Community Action Program Plan (CAP Plan) that
must include a description of how they will establish and/or maintain linkages per Section 676(b)(5).
Eligible entities develop linkages to fill identified gaps in services, through the provision of information,
referrals, case management, and follow-up consultations. Some eligible entities develop linkages with local
private organizations, such as financial institutions, to develop individual development account programs.
Others contract with local non-profit agencies to provide specific services in their communities not offered
by the eligible entity, such as food banks and job training programs. Some of these relationships are
informal, others are subcontracted, and still others operate under Memorandums of Understanding
(MOUs). See Attachment 6, Scope of Work and Attachments 14.1a and 14.1b, Section 14 Narrative
Responses - CSBG Programmatic Assurances and Information Narrative.
9.3b State Assurance of Eligible Entity Linkages to Fill Service Gaps: Describe how the eligible
entities will develop linkages to fill identified gaps in the services, through the provision
of information, referrals, case management, and follow-up consultations, according to
the assurance under Section 676(b)(3)(B) of the CSBG Act.
Eligible entities are required by contract to establish linkages to fill service gaps per Section 676(b)(3)(B).
See attached examples provided by select eligible entities. DAAS/CAPS requires eligible entities to describe
in detail, in their annual/biannual CAP Plans and in their five-year contract renewal RFA responses, how
they will fulfill this assurance. See Attachment 6, Scope of Work 2016-2020.
►Attachment 5 Scope of Work 2016-2020 x.pdf
9.4. Workforce Innovation and Opportunity Act (WIOA) Employment and Training Activities: Does
the State intend to include CSBG employment and training activities as part of a WIOA
Combined State Plan, as allowed under the Workforce Innovation and Opportunity Act (as
required by the assurance under Section 676(b)(5) of the CSBG Act)?  Yes  No
9.4a If the State selected “yes” under item 9.4, provide the CSBG-specific information included
in the State’s WIOA Combined Plan. This information includes a description of how the

State and the eligible entities will coordinate the provision of employment and training
activities through statewide and local WIOA workforce development systems. This
information may also include examples of innovative employment and training programs
and activities conducted by community action agencies or other neighbor- hood-based
organizations as part of a community antipoverty strategy.
9.4b. If the State selected “no” under item 9.4, describe the coordination of employment and
training activities, as defined in Section 3 of WIOA, by the State and by eligible entities
providing activities through the WIOA system.
Eligible entities are required by DAAS/CAPS to submit a CAP Plan in which a description of how WIOA
coordination activities are conducted is included. DAAS/CAPS initiated coordination with the State WIOA
office in SFY 2015. These efforts will continue in SFY 2017. Some agencies have the WIOA offices on their
own premises, while others make referrals to the nearest WIOA office. DAAS/CAPS interviews eligible
entity staff during monitoring site visits regarding the details of WIOA activities. Updates to this initiative
will be included in the amended two-year Plan for FFY 2018.
[Not amended for FFY 2018.]
9.5. Emergency Energy Crisis Intervention: Describe how the State will assure, where appropriate,
that emergency energy crisis intervention programs under title XXVI (relating to Low-Income
Home Energy Assistance) are conducted in each community in the State, as required by the
assurance under Section 676(b)(6) of the CSBG Act).
DAAS/CAPS coordinates with the Low Income Home Energy Assistance Program (LIHEAP) and the
Temporary Assistance to Needy Families (TANF)-funded State Short-Term Crisis Services (STCS) program
via the Community Action Program Services contracts with eligible entities. CAAs utilize CSBG funds to
manage and deliver energy assistance programs, including emergency energy crisis services.
9.6. State Assurance: Faith-based Organizations, Charitable Groups, Community Organizations:
Describe how the State will assure local eligible entities will coordinate and form
partnerships with other organizations, including faith-based organizations, charitable
groups, and community organizations, according to the State’s assurance under Section
676(b)(9) of the CSBG Act.
This assurance is required by the DAAS/CAPS Community Action Program Services contract. Eligible
entities are required to describe in their CAP Plans and in their five-year RFA response how they will meet
this assurance. State CSBG Program staff inquire at monitoring site visits regarding community
coordination activities. Agencies document these efforts in annual narratives and on their annual CSBG IS
reports.
9.7 Coordination of Eligible Entity 90 Percent Funds with Public/Private Resources: Describe
how the eligible entities will coordinate CSBG 90 percent funds with other public and private
resources, according to the assurance under Section 676(b)(3)(C) of the CSBG Act

DAAS/CAPS requires eligible entities to describe in detail in their annual/biannual CAP Plans and in their
five-year contract RFA responses how they will fulfill this assurance. DAAS/CAPS contract scopes of work
also include the delivery of LIHEAP utility assistance and the State authorized Short Term Crisis Services
funded by TANF. Eligible entities report on these efforts in their Annual CSBG IS Report.
9.8. Coordination among Eligible Entities and State Community Action Association: Describe
State activities for supporting coordination among the eligible entities and the State
Community Action Association.
DAAS/CAPS conducts monthly meetings via teleconference and/or face-to-face meetings with the eligible
entities and the Arizona Community Action Association, and provides funding to the Arizona Community
Action Association for coordination activities.
9.9 Communication with Eligible Entities and the State Community Action Association: In the
table below, describe the State’s plan for communicating with eligible entities, the State
Community Action Association, and other partners under this State Plan. Include
communication about annual hearings and legislative hearings, as described under Section
4, CSBG Hearing Requirements.
Communication Plan
Topic Expected Frequency Format Brief Description of ''Other''
1 Alerts Quarterly Other Website and email - Include contract, program,
funding information and technical assistance
2 Face-to-Face Meetings Quarterly Meetings/Presentation
3 Tele-Conferences Other Meetings/Presentation Monthly except where a Face-to-Face Meeting is
scheduled.
4 Public Hearings Annually Meetings/Presentation
5 Legislative Hearings Other Meetings/Presentation Every 3 years
General information regarding
Community Action Programs and
6 specific information regarding Daily Website
LIHEAP and TANF funded crisis
services
9.10. Feedback to Eligible Entities and State Community Action Association: Describe how the
State will provide feedback to local entities and State Community Action Associations
regarding performance on State Accountability Measures.
DAAS/CAPS has initiated discussions with the Network in 2016 on State Accountability Measures. A more
detailed narrative for this item is being developed in coordination with the Network for the FFY 2018 CSBG
State Plan Amendment. Topics under consideration for DAAS/CAPS to provide regular communications
for are: Annual Report (CSBG IS), written feedback and State community engagement activities.
9.11. Performance Management Adjustment: How is the State adjusting the Communication Plan in
this State Plan as compared to past plans? Any adjustment should be based on the State’s
analysis of past performance, and should consider feedback from eligible entities, OCS, and
other sources, such as the public hearing. If the State is not making any adjustments, provide

further detail.
A Communication Plan is being developed in coordination with the Network. A narrative response to this
item will be provided for the FFY 2018 CSBG State Plan Amendment. For this Amendment: DAAS/CAPS
will address a written communication plan in coordination with the Network in SFY 2019, as the State and
the Network are at work on the priorities of implementing ROMA next generation and the CSBG Annual
report, as well as improving a joint Training and Technical Assistance Plan.
End of Section 9

SECTION 10
Monitoring, Corrective Action, and Fiscal Controls
Monitoring of Eligible Entities (Section 678B(a) of the CSBG Act)
10.1. Specify the proposed schedule for planned monitoring visits including: full on-site reviews; on-
site reviews of newly designated entities; follow-up reviews – including return visits to entities
that failed to meet State goals, standards, and requirements; and other reviews as appropriate.
This is an estimated schedule to assist States in planning. States may indicate “no review”
for entities the State does not plan to monitor in the performance period.
For States that have a monitoring approach that does not fit within the table
parameters, attach the State’s proposed monitoring schedule.
CSBG Eligible Entity Review Type Target Date Date of Last Full Brief Description of
Onsite Review “Other”
(if applicable)
Dropdown Dropdown Options:
Options: • FY1 Q1 Formatted: Highlight
• FY1 Q2 If “Other" is selected in
• Full onsite • FY1 Q3 column 2, describe in
Will auto-populate from • Newly • FY1 Q4 Select a date this column
item 5.1 Designated • FY2 Q1
• Follow-up • FY2 Q2
• Other • FY2 Q3
• No review • FY2 Q4
PPEP 8/17
Pima County 9/17
Gila County 11/17
City of Phoenix 12/17
City of Glendale 1/18
Maricopa County 4/18
NACOG 5/18
[For this amendment: DAAS/CAPS will update this section prior to posting the draft plan online for public
inspection, and after the Network is informed of the SFY 2018-2019 monitoring schedule.]

10.2. Monitoring Policies: Provide a copy of State monitoring policies and procedures by
attaching and/or providing a hyperlink.
►State Subrecipient Monitoring Policies
See Attachment 8 subrecipient_monitoring.pdf. This policy covers the fiscal portion of DES subrecipient
contracts. DAAS/CAPS does not have a written monitoring policy regarding programmatic elements of
CSBG. DAAS/CAPS follows CSBG Statute, the contract scope of work, and the CSBG Organizational
Standards when monitoring eligible entities.
10.3. Initial Monitoring Reports: According to the State’s procedures, by how many calendar days
must the State disseminate initial monitoring reports to local entities?
30
Corrective Action, Termination and Reduction of Funding and Assurance Requirements (Section 678C
of the Act)
10.4. Closing Findings: Are State procedures for addressing eligible entity findings/deficiencies, and
the documenting of closure of findings included in the State monitoring protocols attached
above? Yes  No10.4a. If no, describe State procedures for addressing eligible entity
findings/deficiencies, and the documenting of closure of findings.
Currently, DAAS/CAPS prepares a Corrective Improvement Plan (CIP) and tracks time-bound objectives
toward the remedy of findings and deficiencies. For serious deficiencies, the State Office of Procurement
may issue a demand for assurance letter to the eligible entity for findings related to fiscal and administrative
terms and conditions of the DAAS/CAPS contract. DAAS/CAPS follows up with the agency to assure the
completion of the CIP, making follow up visits if necessary and providing technical assistance.
DAAS/CAPS is developing a TAP tool to be used to track technical assistance and efforts toward
compliance where it is more appropriate for DAAS/CAPS to assist eligible entities in achieving compliance
than it is to make findings.[Needs more work]
10.5. Quality Improvement Plans (QIPs): How many eligible entities are currently on Quality
Improvement Plans?
0
10.6. Reporting of QIPs: Describe the State’s process for reporting eligible entities on QIPs to the
Office of Community Services within 30 calendar days of the State approving a QIP?
DAAS/CAPS does not currently report eligible entities on QIPs to the Office of Community Services. As
the CSBG Organizational Standards are still in the State approved assessment and implementation period
until SFY 2018. Eligible entities that do not meet all applicable Standards according to the State
Assessment in SFY 2017, will be assisted as needed to become compliant beginning in SFY 2018.
DAAS/CAPS will implement TAPs in SFY 2018 for agencies needing assistance in their compliance efforts.
DAAS/CAPS does not currently have any eligible entities on QIPs.

10.7. Assurance on Funding Reduction or Termination: Does the State assure, according to Section
676(b)(8), that “any eligible entity that received CSBG funding the previous fiscal year will not
have its funding terminated or reduced below the proportional share of funding the entity
received in the previous fiscal year unless, after providing notice and an opportunity for a
hearing on the record, the State determines that cause exists for such termination or such
reduction, subject to review by the Secretary as provided in Section 678C(b).”  Yes  No
Note: This response will link with the corresponding assurance under item 14.8.
Policies on Eligible Entity Designation, De-designation, and Re-designation
10.8. Does the State CSBG statute and/or regulations provide for the designation of new eligible
entities? Yes  No
10.8a. If yes, provide the citation(s) of the law and/or regulation. If no, describe State
procedures for the designation of new eligible entities.
Currently, DAAS/CAPS has placed a moratorium on the designation of new eligible entities
and the division of service areas by the State or the Network. A new entity designation would
only occur as a result of an existing entity being de-designated, either voluntarily or for cause.
In this instance, DAAS/CAPS would initiate a public solicitation process in coordination with
the State Office of Procurement within the unserved area. A public hearing is held in the
unserved area to inform the community of the proposed designation. A public Request for
Proposals is published via the State Office of Procurement website, www.ProcureAZ.gov .
Local human service agencies may submit proposals for designation that contain all federal
assurances under CSBG, and State assurances as required. An evaluation committee within
DAAS/CAPS determines the best qualified agency to be designated based upon qualifications
stated and completeness of response to required assurances in the RFP response. The agency
selected then completes a Request for Applications (RFA) response package identical to the
RFA completed by existing eligible entities every five years as mentioned 10.10a below. This
RFA includes federal CSBG assurances, agency fiscal information, and a detailed Scope of
Work that includes allowable and required activities under the Community Action Program
Services contract. During the annual State public hearing process, the statewide public at
large will be informed of the designation of a new entity. DAAS/CAPS will follow Public Law
105-285, Title II Â Community Services Block Grant Act, Section 676A.
10.9. Does the State CSBG statute and/or regulations provide for de-designation of eligible entities?
 Yes  No
10.9a. If yes, provide the citation(s) of the law and/or regulation. If no, describe State
procedures for de-designation of new eligible entities.
There is no State CSBG statute or regulation regarding the de-designation of eligible
entities. DAAS/CAPS will follow Public Law 105-285, Title II Â Community Services
Block Grant Act, Section 678C, and the guidance provided in Information
Memorandum No. 116, Corrective Action, Termination, or Reduction of Funding, in
the event of the de-designation of an eligible entity.
10.10. Does the State CSBG statute and/or regulations specify a process the State CSBG agency must

follow to re-designate an existing eligible entity?  Yes  No
10.10a. If yes, provide the citation(s) of the law and/or regulation. If no, describe State
procedures for re-designation of existing eligible entities.
Fiscal Controls and Audits and Cooperation Assurance
10.11. Fiscal Controls and Accounting: Describe how the State’s fiscal controls and accounting
procedures will a) permit preparation of the SF-425 Federal fiscal reports (FFR) and b) permit
the tracing of expenditures adequate to ensure funds have been used appropriately under the
block grant, as required by Block Grant regulations applicable to CSBG at 45 CFR 96.30(a).
The State has established fiscal controls, procedures, audits, and inspections, as required under Sections
678D(a)(1) and 678D(a)(2) of the Act. Arizona assures that fiscal control and fund accounting procedures
established shall be sufficient to assure the proper disbursal of and accounting for federal funds paid to the State
under this subtitle, including procedures for monitoring the assistance provided under this subtitle. Arizona
assures the eligible entities and any other recipients of funds under this subtitle shall comply with the Office of
Management and Budget cost and accounting principles. These assurances will be implemented by the State
and/or through contract agreements with service providers. Each provider agreement will include requirements
that the provider adhere to these areas as applicable to them.
10.12. Single Audit Management Decisions: Describe State procedures for issuing management
decisions for eligible entity single audits, as required by Block Grant regulations applicable to
CSBG at 45 CFR 75.521. If these procedures are described in the State monitoring protocols
attached under item 10.2, indicate the page number.
At least annually, each state, local government and American Indian Tribe or tribal organization that
receives $100,000 or more (during the fiscal year) in all types of federal financial assistance must conduct
an audit in accordance with the Single Audit Act, Public Law 98-502. [31 U.S.C. 75 and OMB Circular A-
128), ‘678D(a)(1) and ‘678D(a)(2)]
The State further assures that a copy of such audit shall be made available to the eligible entities, State
Legislature and the Secretary of the U.S. Department of Health and Human Services.
10.13. Assurance on Federal Investigations: Will the State “permit and cooperate with Federal
investigations undertaken in accordance with Section 678D” of the CSBG Act, as required by the
assurance under Section 676(b)(7) of the CSBG Act?  Yes  No
Note: This response will link with the corresponding assurance, item 14.7
10.14. Performance Management Adjustment: How is the State adjusting monitoring procedures in
this State Plan as compared to past plans? Any adjustment should be based on the State’s
analysis of past performance, and should consider feedback from eligible entities, OCS, and
other sources, such as the public hearing. If this State is not making any adjustments, provide

further detail.
DAAS/CAPS does not have plans to revise its monitoring processes for SFY 2017, except for the adoption
of a tool for assessing compliance with the CSBG Organizational Standards that was developed in
conjunction with the Network. Any adjustments following internal discussion and feedback from eligible
entities will be described in the amendment for FFY 2018. Current monitoring includes the following for
assessing the CAAs status in implementing the CSBG Organizational Standards. Beginning in SFY 2016
and continuing in SFY 2017, the State is conducting an informal assessment of each eligible entity using
the same model. The informal assessment will be conducted in conjunction with the existing monitoring
schedule. The intent of this assessment is to identify training and technical assistance needs. Agencies in
need of technical assistance may request State assessment and technical assistance earlier than their
scheduled monitoring dates. The ADES will provide appropriate technical assistance to support eligible
entities in achieving compliance with the organizational standards. The State will require full compliance
with the organizational standards, as may be amended, by SFY 2018, and will monitor each eligible entity
in accordance with its regular monitoring schedule.
For this amendment: In SFY 2018, DAAS/CAPS anticipates all agencies will reach full
compliance with the CSBG Organizational Standards or
End of Section 10

SECTION 11
Eligible Entity Tripartite Board
11.1. Which of the following measures are taken to ensure that the State verifies CSBG Eligible
Entities are meeting Tripartite Board requirements under Section 676B of the CSBG Act? [Check
all that applies and narrative where applicable]
 Attend Board meetings
 Review copies of Board meeting minutes
 Track Board vacancies/composition
 Other [Narrative, 2500 Characters]
11.2. How often does the State require eligible entities (which are not on TAPs or QIPs) to provide
updates (e.g., copies of meeting minutes, vacancy alerts, changes to bylaws, low-income
member selection process, etc.) regarding their Tripartite Boards? [Check all that applies and
narrative where applicable]
 Annually
 Semiannually
 Quarterly
 Monthly
 Other [Narrative, 2500 Characters]
11.3. Assurance on Eligible Entity Tripartite Board Representation: Describe how the State will carry
out the assurance under Section 676(b)(10) of the CSBG Act that the State will require eligible
entities to have policies and procedures by which individuals or organizations can petition for
adequate representation on an eligible entities’ Tripartite Board.
DAAS/CAPS will require that each eligible entity in the State establish procedures under which a low-
income individual, community organization, religious organization, or representative of low-income
individuals that considers its organization or low-income individuals to be inadequately represented on the
board (or other mechanism) of the eligible entity can petition for adequate representation.
11.4. Does the State permit public eligible entities to use, as an alternative to a Tripartite Board,
“another mechanism specified by the State to assure decision-making and participation by low-
income individuals in the development, planning, implementation, and evaluation of programs”
as allowed under Section 676B(b)(2) of the CSBG Act.  Yes  No
11.4a. If yes, describe the mechanism used by public eligible entities as an alternative to a
Tripartite Board.
Private non-profit eligible entities are required to seat a tripartite board as set forth in Section 676B(b)(1)
of the Act. Public entities may follow the provision stated above from 676B(b)(2) of the CSBG Act. The
DAAS/CAPS contract Scope of Work Section 9.3.2 for public eligible entities reads as follows: “Select
members to serve on a Board in which one-third of the board members are persons chosen in accordance
with democratic selection procedures adequate to assure that these members are representative of low-

income individuals and families. Select representatives to fill balance of seats as set forth in governing
documents.” Currently, all public eligible entities voluntarily maintain tripartite boards per Section
676B(b)(1) of the Act.
End of Section 11

SECTION 12
Individual and Community Income Eligibility Requirements
12.1. Required Income Eligibility: What is the income eligibility threshold for services in the State?
[Check one item below.]
 125% of the HHS poverty line
 150 % of the HHS poverty line (fill in the threshold): 150% [insert up to a 3 digit
percentage]
 Varies by eligible entity
12.1a. Describe any State policy and/or procedures for income eligibility, such as treatment of
income and family/household composition. [Narrative, 2500 Characters, or attachment]
Income eligibility statewide varies by program. DAAS/CAPS follows program rules and State laws for
State and federally funded programs conducted under Community Action Program Services contracts. For
CSBG funded crisis services, eligible entities may set the income eligibility threshold at 150 percent of the
federal poverty level for households with one or more members that are seniors aged 60 and over, or
persons with disabilities. Households that do not meet this criteria are income eligible at or below 125
percent of poverty. This is in keeping with State laws regarding assistance provided under the TANF funded
Short-Term Crisis Services (STCS), as set forth in Title 6, Article 8 of the Arizona Administrative Code.
This uniform eligibility threshold maintains fairness for households without children that have one or more
vulnerable members, but do not qualify for crisis services under STCS/TANF. Using a uniform threshold
and criteria avoids confusion, offers flexibility for case managed clients, reduces the administrative burden
on eligible entities and will reduce technical assistance requests to DAAS/CAPS. The income eligibility
limit for LIHEAP energy assistance programs administered with CSBG dollars is 60 percent of the State
Median Income (SMI), adjusted for household size; or 150 percent of the Federal Poverty Guideline (FPG),
whichever is greater for a given household. For SFY 2016 in Arizona, the FPG is greater for households
with seven or more members.
See Attachments 5 and 10 Income Thresholds

12.2. Income Eligibility for General/Short Term Services: For services with limited in-take procedures
(where individual income verification is not possible or practical), how does the State ensure
eligible entities generally verify income eligibility for services? An example of these services is
emergency food assistance.
All Eligible entities are required by contract and State laws verify program eligibility for CSBG supported
services where required by program rules. Eligible entities target limited intake, general and short-term
community based services such as: medical copay and prescription assistance, school supply, clothing and
personal care product and emergency food assistance, to existing case managed client households. Eligible
entities coordinate extensively with local partners in delivering these community based services to the
households in the greatest need. CAAs may conduct or promote periodic mass events offering the services
mentioned above by inviting program participants from their own and/or partners client lists who are
known to have qualified for benefits. For this amendment: Income eligibility for CSBG funded direct
services will follow the rules for the service being provided. If CSBG funds are used to provide a service
under the Short Term Crisis Services, the income eligibility requirements for that program will apply.
Conversely, for utility assistance, the income eligibility requirements would follow those for LIHEAP.
Eligible entities may consider income eligibility for TANF funded or LIHEAP funded programs to indicate
categorical income eligibility for any CSBG funded service.
12.3. Community-Targeted Services: For services that provide a community-wide benefit (e.g.,
development of community assets/facilities, building partnerships with other organizations),
how does the State ensure eligible entities’ services target and benefit low-income
communities?
Some eligible entities offer community targeted services within their own or partner facilities that are
located in low-income neighborhoods and/or senior centers. For example, some eligible entities
coordinate with local education institutions and refer existing case managed households to community
based education services. Still others offer community based services themselves at their own facilities
and make them available to client households and applicants. These services include financial services,
community gardens, career centers, education, and income management. DAAS/CAPS documents these
activities during monitoring visits and encourages eligible entities to submit program narratives annually
to highlight these activities.
End of Section 12

SECTION 13
Results Oriented Management and Accountability (ROMA) System
13.1. ROMA Participation: In which performance measurement system will the State and all eligible
entities participate, as required by Section 678E(a) of the CSBG Act and the assurance under
Section 676(b)(12) of the CSBG Act?
 The Results Oriented Management and Accountability (ROMA) System
 Another performance management system that meets the requirements of section 678E(b)
of the CSBG Act
 An alternative system for measuring performance and results
13.1a. If ROMA was selected in item 13.1, attach and/or describe the State’s written policies,
procedures, or guidance documents on ROMA.
Participation and utilization of ROMA in program planning is required by DAAS/CAPS Community Action
Program Services contracts. DAAS/CAPS utilizes guidance from federal partners and OCS IMs 49, and 82.
See Community Action Program Services Scope of Work (SOW) sections 9.2.1 and 9.4.1
►Attachment. SOW 2016-2020Attachment 5 Scope of Work 2016-2020 x.pdf
13.1b. If ROMA was not selected in item 13.1, describe the system the State will use for
performance measurement.
13.2. Indicate and describe the outcome measures the State will use to measure eligible entity
performance in promoting self-sufficiency, family stability, and community revitalization, as
required under Section 676(b)(12) of the CSBG Act?
 CSBG National Performance Indicators (NPIs)
 NPIs and others
 Others
13.3. How does the State support the eligible entities in using the ROMA system (or alternative
performance measurement system)?
DAAS/CAPS provides funds to the Arizona Community Action Association to provide ROMA training and
offers technical assistance to individual eligible entities upon request, responding to questions and
conducting research on the agency’s behalf.
[Not Amended]
13.4. Eligible Entity Use of Data: How is the State validating that the eligible entities are using data to
improve service delivery?
DAAS/CAPS program staff interview agency staff and Tripartite Board members, attend board meetings and
review meeting minutes to ascertain the agency’s use of ROMA NPIs to evaluate programs. Agencies

demonstrate the use of data through formal decisions made in Board meetings relative to data collected in
the previous program year.
[Not Amended]
Community Action Plans and Needs Assessments
13.5. Describe how the State will secure a Community Action Plan from each eligible entity, as a
condition of receipt of CSBG funding by each entity, as required by Section 676(b)(11) of the
CSBG Act. [
Submission of a Community Action Plan by the eligible entities is required by contract at least once every
two years, and during the contract renewal period, as part of the eligible entity’s application package. For
this Amendment: DAAS/CAPS has begun work with ACAA to develop a new model CAP Plan that should
be completed during SFY 2018.
Put a calendar-Timelines here
13.6. State Assurance: Describe how the State will assure that each eligible entity includes a
community needs assessment for the community served (which may be coordinated with
community needs assessments conducted by other programs) in each entity’s Community Action
Plan, as required by Section 676(b)(11) of the CSBG Act.
Submission of a Community Needs Assessment is required by contract at least once every three years. This
period may be extended for eligible entities with an active assessment project under way during the year
the assessment document is due. An extension may also be granted by DAAS/CAPS for agencies
coordinating community assessments with other programs such as Head Start. Agencies requesting
extensions must demonstrate that they are engaged in an active assessment project and provide a written
methodology and timeline for completion.
End of Section 13

SECTION 14
CSBG Programmatic Assurances and Information Narrative
(Section 676(b) of the CSBG Act)
14.1 Use of Funds Supporting Local Activities
CSBG Services
14.1a. 676(b)(1)(A): Describe how the State will assure “that funds made available through
grant or allotment will be used –
(A) to support activities that are designed to assist low-income families and individuals,
including families and individuals receiving assistance under title IV of the Social
Security Act, homeless families and individuals, migrant or seasonal farmworkers,
and elderly low-income individuals and families, and a description of how such
activities will enable the families and individuals--
(i) to remove obstacles and solve problems that block the achievement of self-
sufficiency (particularly for families and individuals who are attempting to
transition off a State program carried out under part A of title IV of the Social
Security Act);
(ii) to secure and retain meaningful employment;
(iii) to attain an adequate education with particular attention toward improving
literacy skills of the low-income families in the community, which may
include family literacy initiatives;
(iv) to make better use of available income;
(v) to obtain and maintain adequate housing and a suitable living environment;
(vi) to obtain emergency assistance through loans, grants, or other means to
meet immediate and urgent individual and family needs;
(vii) to achieve greater participation in the affairs of the communities involved,
including the development of public and private grassroots partnerships with
local law enforcement agencies, local housing authorities, private
foundations, and other public and private partners to –
(I) document best practices based on successful grassroots intervention in
urban areas, to develop methodologies for widespread replication; and
(II) strengthen and improve relationships with local law enforcement
agencies, which may include participation in activities such as
neighborhood or community policing efforts;
DAAS/CAPS requires CSBG eligible entities to submit an annual Community Action Plan (CAP). The CAP
includes written Service and Administrative Methodologies that outline their proposed activities. These
activities are required to align with the eligible entities’ Community Needs Assessments and their contract
scope of work. Staff reviews the CAP Plan and ensures that the activities supported are eligible uses of
CSBG funds and meet the noted assurances. [not amended for 2018]

Needs of Youth
14.1b. 676(b)(1)(B) Describe how the State will assure “that funds made available through
grant or allotment will be used –
(B) to address the needs of youth in low-income communities through youth
development programs that support the primary role of the family, give priority to
the prevention of youth problems and crime, and promote increased community
coordination and collaboration in meeting the needs of youth, and support
development and expansion of innovative community-based youth development
programs that have demonstrated success in preventing or reducing youth crime,
such as--
(i) programs for the establishment of violence-free zones that would involve
youth development and intervention models (such as models involving youth
mediation, youth mentoring, life skills training, job creation, and
entrepreneurship programs); and
(ii) after-school child care programs;
DAAS/CAPS requires CSBG eligible entities to submit an annual Community Action Program Plan (CAP
Plan). The CAP Plan includes a description that outlines proposed activities. DAAS/CAPS staff reviews the
CAP Plan and ensures that the activities supported are eligible uses of CSBG funds. DAAS/CAPS requires
a referral to the DES Division of Child Support Enforcement Office for heads of households who are
single/divorced custodial parents not currently receiving child support. In ongoing efforts to avoid
duplication of services, DAAS/CAPS does not directly operate or support after school child care programs,
as these are available through other programs in the communities served. Eligible entities are required by
their contracts, to set forth in their written administrative and service methodologies, a description of how
they will support these programs through coordination with community partners, federally funded
programs, such as Head-Start, and referrals to local and private programs. For examples, see Attachment
14.1b - Needs of Youth. [Not amended for FFY 2018]
►Attachment Attachment 14.1b - Needs of Youth.doc
Coordination of Other Programs
14.1c. 676(b)(1)(C) Describe how the State will assure “that funds made available through
grant or allotment will be used –
(C) to make more effective use of, and to coordinate with, other programs related to
the purposes of this subtitle (including State welfare reform efforts)
DAAS CAPS requires CSBG eligible entities to submit an annual Community Action Program Plan (CAP
Plan). The CAP Plan includes a description of its plans and ongoing efforts to coordinate programs in its
service area. Staff reviews the CAP Plan and ensures that the activities supported are eligible uses of CSBG
funds and coordination. At the State level, The State Human Services agency, DES, coordinates a variety
of programs using State and federal resources including Supplemental Nutrition Assistance Program
(SNAP), and Workforce Innovation and Opportunity Act (WIOA), Temporary Assistance for Needy Families
(TANF) Medicaid, Department of Housing and Urban Development (HUD), Department of Labor (DOL)
programs. DAAS/CAPS includes in its Community Action Programs and Services contracts with eligible
entities, the Low-Income Home Energy Assistance Program (LIHEAP), Short-Term Crisis Services
(STCS/TANF), and other State and county funds. Current DES agency-wide outreach efforts conducted by

the Office of Community Engagement are working to coordinate the various State service departments with
other local private, and faith-based organizations including, Community Action Agencies. DAAS/CAPS
staff participate in the activities of this office. DAAS/CAPS also supports the State Association, the Arizona
Community Action Association (ACAA), in its efforts to coordinate with the Community Action Network as
a whole, to develop and maintain relationships with other State and local agencies, federal programs, and
information and referral systems. . [Not amended for FFY 2018]
State Use of Discretionary Funds
14.2 676(b)(2) Describe “how the State intends to use discretionary funds made available from the
remainder of the grant or allotment described in section 675C(b) in accordance with
this subtitle, including a description of how the State will support innovative
community and neighborhood-based initiatives related to the purposes of this
subtitle.”
Note: The State describes this assurance under "State Use of Funds: Remainder/Discretionary," items 7.9
and 7.10 [Not amended for FFY 2018]
►Attachment Attachment 3 Allocations 2018.docx
Eligible Entity Service Delivery, Coordination, and Innovation
14.3. 676(b)(3) “Based on information provided by eligible entities in the State, a description of…”
Eligible Entity Service Delivery System
14.3a. 676(b)(3)(A) Describe “the service delivery system, for services provided or coordinated
with funds made available through grants made under 675C(a), targeted to low-income
individuals and families in communities within the State;
The Department requires CSBG eligible entities to submit an annual Community Action Program Plan
(CAP Plan) and contract documents that include a description of the service delivery system, the county
or counties served, the facilities where services are available, and information regarding how the eligible
entity conducts outreach and delivers services in counties where service centers are not available. The
CAP Plan also describes how the eligible entity coordinates funds with other organizations. The eleven
CAAs in Arizona are contracted by DAAS/CAPS under their Community Action Programs and Services
contract to provide services through the Low Income Home Energy Assistance Program (LIHEAP).
DAAS/CAPS also contracts with the Arizona Department of Housing to provide Weatherization services
in coordination with funding from the Department of Energy, which in turn subcontracts with nine eligible
entities, and one additional sub-grantee, to offer Weatherization services. All eligible entities are required
by contract to utilize CSBG funding in coordination with funding from Temporary Assistance for Needy
Families (TANF), to deliver the State mandated emergency assistance program, Short Term Crisis
Services (STCS). The State may award CSBG discretionary funds to support enhanced service methods,
innovative special projects, and partnership initiatives. [Not amended for FFY 2018]
Eligible Entity Linkages – Approach to Filling Service Gaps
14.3b. 676(b)(3)(B) Describe “how linkages will be developed to fill identified gaps in the
services, through the provision of information, referrals, case management,

and follow up consultations.”
Note: The State describes this assurance in the State Linkages and Communication section, item
9.3b.
Coordination of Eligible Entity Allocation 90 Percent Funds with Public/Private Resources
14.3c. 676(b)(3)(C) Describe how funds made available through grants made under 675C(a)will
be coordinated with other public and private resources.”
Note: The State describes this assurance in the State Linkages and Communication section, item
9.7.
Eligible Entity Innovative Community and Neighborhood Initiatives, Including
Fatherhood/Parental Responsibility
14.3d. 676(b)(3)(D) Describe “how the local entity will use the funds [made available under
675C(a)] to support innovative community and neighborhood-based
initiatives related to the purposes of this subtitle, which may include
fatherhood initiatives and other initiatives with the goal of strengthening
families and encouraging parenting.”
DAAS/CAPS requires CSBG eligible entities to submit an annual Community Action Program
Plan (CAP Plan), in which the entities describe how CSBG funds will be used to meet the noted
assurance.
Eligible Entity Emergency Food and Nutrition Services
14.4. 676(b)(4) Describe how the State will assure “that eligible entities in the State will provide, on an
emergency basis, for the provision of such supplies and services, nutritious foods, and
related services, as may be necessary to counteract conditions of starvation and
malnutrition among low-income individuals.”
DAAS/CAPS requires CSBG eligible entities to submit an annual Community Action
Program Plan (CAP Plan). As part of the CAP Plan, eligible entities must provide a
description of how the eligible entity will provide, on an emergency basis, for the
provision of such supplies and services, nutritious foods, and related services, as may be
necessary to counteract conditions of starvation and malnutrition among low-income
individuals. Most CSBG eligible entities work with either a local food pantry, a food bank,
or operate their own emergency food service in house, to provide food in these
circumstances. Some eligible entities subcontract with local charities that provide
emergency food as part of their suite of services. Some eligible entities also coordinate
with the State Supplemental Nutrition Assistance Program (SNAP) to facilitate
applications for State nutritional assistance. Under eligible entities' contracts with
DAAS/CAPS, CSBG funds may be used to support emergency food program operations.
If the cases of emergent need that cannot be met immediately through other programs,
eligible entities may utilize CSBG funds to meet food emergencies by providing food cards
to qualified low-income households. In the case of a local emergency or disaster in low-
income neighborhoods, eligible entities may be authorized by DAAS/CAPS to utilize

CSBG discretionary funds to provide temporary shelter and/or emergency food to
affected residents. [Not amended for FFY 2018]
State and Eligible Entity Coordination/linkages and Workforce Innovation and Opportunity Act
Employment and Training Activities
14.5. 676(b)(5) Describe how the State will assure “that the State and eligible entities in the State
will coordinate, and establish linkages between, governmental and other social
services programs to assure the effective delivery of such services, and [describe]
how the State and the eligible entities will coordinate the provision of employment
and training activities, as defined in section 3 of the Workforce Innovation and
Opportunity Act, in the State and in communities with entities providing activities
through statewide and local workforce development systems under such Act.”
Note: The State describes this assurance in the State Linkages and Communication section,
items 9.1, 9.2, 9.3a, 9.4, 9.4a, and 9.4b.
State Coordination/Linkages and Low-income Home Energy
Assistance
14.6. 676(b)(6) Provide “an assurance that the State will ensure coordination between antipoverty
programs in each community in the State, and ensure, where appropriate, that emergency
energy crisis intervention programs under title XXVI (relating to low- income home energy
assistance) are conducted in such community.”
Note: The State describes this assurance in the State Linkages and Communication section,
items 9.2 and 9.5.
[No response; links to 9.2 and 9.5]
Federal Investigations
14.7. 676(b)(7) Provide “an assurance that the State will permit and cooperate with Federal
investigations undertaken in accordance with section 678D.”
Note: the State addresses this assurance in the Fiscal Controls and Monitoring section, item
10.13. [No response; links to 10.13]

Funding Reduction or Termination
14.8. 676(b)(8) Provide “an assurance that any eligible entity in the State that received funding in
the previous fiscal year through a community services block grant made under this
subtitle will not have its funding terminated under this subtitle, or reduced below
the proportional share of funding the entity received in the previous fiscal year
unless, after providing notice and an opportunity for a hearing on the record, the
State determines that cause exists for such termination or such reduction, subject to
review by the Secretary as provided in section 678C(b).”
Note: the State addresses this assurance in the Fiscal Controls and Monitoring section, item
10.7. [No response; links to 10.7]
Coordination with Faith-based Organizations, Charitable Groups, Community Organizations
14.9. 676(b)(9) Describe how the State will assure “that the State and eligible entities in the State
will, to the maximum extent possible, coordinate programs with and form
partnerships with other organizations serving low-income residents of the
communities and members of the groups served by the State, including religious
organizations, charitable groups, and community organizations.”
Note: the State describes this assurance in the State Linkages and Communication section, item
9.6. [No response; links to 9.6]
Eligible Entity Tripartite Board Representation
14.10. 676(b)(10) Describe how “the State will require each eligible entity in the State to establish
procedures under which a low-income individual, community organization, or
religious organization, or representative of low-income individuals that considers its
organization, or low-income individuals, to be inadequately represented on the
board (or other mechanism) of the eligible entity to petition for adequate
representation.”
Note: the State describes this assurance in the Eligible Entity Tripartite Board section, 11.3. [No
response; links to item 11.3]
Eligible Entity Community Action Plans and Community Needs Assessments
14.11. 676(b)(11) Provide “an assurance that the State will secure from each eligible entity in the
State, as a condition to receipt of funding by the entity through a community
services block grant made under this subtitle for a program, a community action
plan (which shall be submitted to the Secretary, at the request of the Secretary, with
the State plan) that includes a community-needs assessment for the community
served, which may be coordinated with community-needs assessments conducted
for other programs.”
[No response; links to items 13.5 and 13.6]

State and Eligible Entity Performance Measurement: ROMA or Alternate system
14.12. 676(b)(12) Provide “an assurance that the State and all eligible entities in the State will, not
later than fiscal year 2001, participate in the Results Oriented Management and
Accountability System, another performance measure system for which the
Secretary facilitated development pursuant to section 678E(b), or an alternative
system for measuring performance and results that meets the requirements of that
section, and [describe] outcome measures to be used to measure eligible entity
performance in promoting self-sufficiency, family stability, and community
revitalization.”
Note: The State describes this assurance in the ROMA section, items 13.1, 13.2, 13.3, and 13.4.
[No response; links to 13.1, 13.2, 13.3, and 13.4]
Validation for CSBG Eligible Entity Programmatic Narrative Sections
14.13. 676(b)(13) Provide “information describing how the State will carry out the assurances
described in this section.”
Note: The State provides information for each of the assurances directly in section 14 or in
corresponding items throughout the State Plan, which are included as hyperlinks in section 14.
[No response for this item]
 By checking this box, the State CSBG authorized official is certifying the assurances set out
above.
- End of Section 14

SECTION 15
Federal Certifications
The box after each certification must be checked by the State CSBG authorized official.
15.1 Lobbying
Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee of
an agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the awarding of any Federal contract, the making of
any Federal grant, the making of any Federal loan, the entering into of any cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress or an employee of a Member of Congress in
connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned
shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in
accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly. This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S.
Code. Any person who fails to file the required certification shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to influence an
officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with this commitment providing for the United
States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL,
“Disclosure Form to Report Lobbying,” in accordance with its instructions. Submission of this
statement is a prerequisite for making or entering into this transaction imposed by section 1352, title

31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil
penalty of not less than $10,000 and not more than $100,000 for each such failure.
 By checking this box, the State CSBG authorized official is providing the certification set
out above.
15.2 Drug-Free Workplace Requirements
This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45
CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645 (a)(1) and (b) provide that a Federal
agency may designate a central receipt point for STATE-WIDE AND STATE AGENCY-WIDE
certifications, and for notification of criminal drug convictions. For the Department of Health and
Human Services, the central point is: Division of Grants Management and Oversight, Office of
Management and Acquisition, Department of Health and Human Services, Room 517-D, 200
Independence Avenue, SW Washington, DC 20201.
Certification Regarding Drug-Free Workplace Requirements (Instructions for Certification)
(1) By signing and/or submitting this application or grant agreement, the grantee is providing
the certification set out below.
(2) The certification set out below is a material representation of fact upon which reliance is
placed when the agency awards the grant. If it is later determined that the grantee knowingly
rendered a false certification, or otherwise violates the requirements of the Drug-
Free Workplace Act, the agency, in addition to any other remedies available to the
Federal Government, may take action authorized under the Drug-Free Workplace
Act.
(3) For grantees other than individuals, Alternate I
applies. (4) For grantees who are individuals, Alternate II
applies.
(5) Workplaces under grants, for grantees other than individuals, need to be identified on the
certification. If known, they may be identified in the grant application. If the grantee does not
identify the workplaces at the time of application, or upon award, if there is no application, the
grantee must keep the identity of the workplace(s) on file in its office and make the
information available for Federal inspection. Failure to identify all known workplaces
constitutes a violation of the grantee’s drug-free workplace requirements.
(6) Workplace identifications must include the actual address of buildings (or parts of buildings)
or other sites where work under the grant takes place. Categorical descriptions may be used
(e.g., all vehicles of a mass transit authority or State highway department while in operation,
State employees in each local unemployment office, performers in concert halls or radio
studios).

(7) If the workplace identified to the agency changes during the performance of the grant, the
grantee shall inform the agency of the change(s), if it previously identified the workplaces
in question (see paragraph five).
(8) Definitions of terms in the Nonprocurement Suspension and Debarment common rule and
Drug-Free Workplace common rule apply to this certification. Grantees’ attention is called,
in particular, to the following definitions from these rules:
Controlled substance means a controlled substance in Schedules I through V of the Controlled
Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);
Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence,
or both, by any judicial body charged with the responsibility to determine violations of the Federal or
State criminal drug statutes;
Criminal drug statute means a Federal or non-Federal criminal statute involving the
manufacture, distribution, dispensing, use, or possession of any controlled substance;
Employee means the employee of a grantee directly engaged in the performance of work under a
grant, including: (i) All direct charge employees; (ii) All indirect charge employees unless their impact
or involvement is insignificant to the performance of the grant; and, (iii) Temporary personnel and
consultants who are directly engaged in the performance of work under the grant and who are on the
grantee’s payroll. This definition does not include workers not on the payroll of the grantee (e.g.,
volunteers, even if used to meet a matching requirement; consultants or independent contractors not
on the grantee’s payroll; or employees of subrecipients or subcontractors in covered workplaces).
Certification Regarding Drug-Free Workplace Requirements
Alternate I. (Grantees Other Than Individuals)
The grantee certifies that it will or will continue to provide a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the grantee’s
workplace and specifying the actions that will be taken against employees for violation of such
prohibition;
(b) Establishing an ongoing drug-free awareness program to inform employees about -
- (1) The dangers of drug abuse in the workplace;
(2) The grantee’s policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in
the workplace;

(c) Making it a requirement that each employee to be engaged in the performance of the grant
be given a copy of the statement required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition
of employment under the grant, the employee will (1) Abide by the terms of the
statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug
statute occurring in the workplace no later than five calendar days after such
conviction;
(e) Notifying the agency in writing, within 10 calendar days after receiving notice under paragraph
(d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of
convicted employees must provide notice, including position title, to every grant officer or other
designee on whose grant activity the convicted employee was working, unless the Federal
agency has designated a central point for the receipt of such notices. Notice shall include the
identification number(s) of each affected grant;
(f) Taking one of the following actions, within 30 calendar days of receiving notice under paragraph
(d)(2), with respect to any employee who is so convicted - -
(1) Taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as
amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health,
law enforcement, or other appropriate agency;
(g) Making a good faith effort to continue to maintain a drug-free workplace
through implementation of paragraphs (a), (b), (c), (d), (e) and (f).
The grantee may insert in the space provided below the site(s) for the performance of work done
in connection with the specific grant:
Place of Performance (Street address, city, county, state, zip code) [Narrative, 2500 Characters]
N/A
Check if there are workplaces on file that are not identified
here. Alternate II. (Grantees Who Are Individuals)
(a) The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful
manufacture, distribution, dispensing, possession, or use of a controlled substance in
conducting any activity with the grant;
(b) If convicted of a criminal drug offense resulting from a violation occurring during the conduct of
any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the

conviction, to every grant officer or other designee, unless the Federal agency designates a
central point for the receipt of such notices. When notice is made to such a central point, it
shall include the identification number(s) of each affected grant. [55 FR 21690, 21702, May 25,
1990]
 By checking this box, the State CSBG authorized official is providing the certification set out above.
15.3 Debarment
CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS
Certification Regarding Debarment, Suspension, and Other Responsibility Matters -
Primary Covered Transactions
Instructions for Certification
(1) By signing and submitting this proposal, the prospective primary participant is providing
the certification set out below.
(2) The inability of a person to provide the certification required below will not necessarily result
in denial of participation in this covered transaction. The prospective participant shall submit
an explanation of why it cannot provide the certification set out below. The certification or
explanation will be considered in connection with the department or agency’s determination
whether to enter into this transaction. However, failure of the prospective primary participant
to furnish a certification or an explanation shall disqualify such person from participation in
this transaction.
(3) The certification in this clause is a material representation of fact upon which reliance was
placed when the department or agency determined to enter into this transaction. If it is
later determined that the prospective primary participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.
(4) The prospective primary participant shall provide immediate written notice to the department
or agency to which this proposal is submitted if at any time the prospective primary participant
learns that its certification was erroneous when submitted or has become erroneous by reason
of changed circumstances.
(5) The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction,
participant, person, primary covered transaction, principal, proposal, and voluntarily excluded,
as used in this clause, have the meanings set out in the Definitions and Coverage sections of the
rules implementing Executive Order 12549. You may contact the department or agency to
which this proposal is being submitted for assistance in obtaining a copy of those regulations.
(6) The prospective primary participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter into any lower tier
covered transaction with a person who is proposed for debarment under 48 CFR part 9,

subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the department or agency
entering into this transaction.
(7) The prospective primary participant further agrees by submitting this proposal that it will
include the clause titled “Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusive-Lower Tier Covered Transaction,” provided by the department or agency
entering into this covered transaction, without modification, in all lower tier covered
transactions and in all solicitations for lower tier covered transactions.
(8) A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that is not proposed for debarment under 48
CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the
covered transaction, unless it knows that the certification is erroneous. A participant may
decide the method and frequency by which it determines the eligibility of its principals. Each
participant may, but is not required to, check the List of Parties Excluded from Federal
Procurement and Nonprocurement Programs.
(9) Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause. The knowledge
and information of a participant is not required to exceed that which is normally possessed by
a prudent person in the ordinary course of business dealings.
(10) Except for transactions authorized under paragraph 6 of these instructions, if a participant in a
covered transaction knowingly enters into a lower tier covered transaction with a person who
is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible,
or voluntarily excluded from participation in this transaction, in addition to other remedies
available to the Federal Government, the department or agency may terminate this transaction
for cause or default.

Certification Regarding Debarment, Suspension, and Other Responsibility Matters
Primary Covered Transactions
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it
and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of or had a
civil judgment rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State or
local) transaction or contract under a public transaction; violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental
entity (Federal, State or local) with commission of any of the offenses enumerated in
paragraph (1)(b) of this certification; and
(d) Have not within a three-year period preceding this application/proposal had one or
more public transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - - Lower Tier
Covered Transactions
Instructions for Certification
(1) By signing and submitting this proposal, the prospective lower tier participant is providing
the certification set out below.
(2) The certification in this clause is a material representation of fact upon which reliance was
(3) placed when this transaction was entered into. If it is later determined that the prospective
lower tier participant knowingly rendered an erroneous certification, in addition to other
remedies available to the Federal Government the department or agency with which this
transaction originated may pursue available remedies, including suspension and/or
debarment.
(4) The prospective lower tier participant shall provide immediate written notice to the person to
which this proposal is submitted if at any time the prospective lower tier participant learns that
its certification was erroneous when submitted or had become erroneous by reason of
changed circumstances.

(5) The terms covered transaction, debarred, suspended, ineligible, lower tier covered
transaction, participant, person, primary covered transaction, principal, proposal, and
voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549. You may contact the person
to which this proposal is submitted for assistance in obtaining a copy of those regulations.
(6) The prospective lower tier participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter into any lower tier
covered transaction with a person who is proposed for debarment under 48 CFR part 9,
subpart
9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in
this covered transaction, unless authorized by the department or agency with which this
transaction originated.
(7) The prospective lower tier participant further agrees by submitting this proposal that it will
include this clause titled “Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion-Lower Tier Covered Transaction,” without modification, in all lower
tier covered transactions and in all solicitations for lower tier covered transactions.
(8) A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not proposed for debarment under
48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from
covered transactions, unless it knows that the certification is erroneous. A participant may
decide the method and frequency by which it determines the eligibility of its principals.
Each participant may, but is not required to, check the List of Parties Excluded from Federal
Procurement and Nonprocurement Programs.
(9) Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause. The knowledge
and information of a participant is not required to exceed that which is normally possessed by
a prudent person in the ordinary course of business dealings.
(10) Except for transactions authorized under paragraph five of these instructions, if a participant in
a covered transaction knowingly enters into a lower tier covered transaction with a person
who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred,
ineligible, or voluntarily excluded from participation in this transaction, in addition to other
remedies available to the Federal Government, the department or agency with which this
transaction originated may pursue available remedies, including suspension and/or
debarment.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - - Lower Tier
Covered Transactions
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither
it nor its principals is presently debarred, suspended, proposed for debarment, declared

ineligible, or voluntarily excluded from participation in this transaction by any Federal
department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
 By checking this box, the State CSBG authorized official is providing the certification set
out above.
15.4 Environmental Tobacco Smoke
Public Law 103227, Part C Environmental Tobacco Smoke, also known as the Pro Children Act of
1994, requires that smoking not be permitted in any portion of any indoor routinely owned or
leased or contracted for by an entity and used routinely or regularly for provision of health,
day care, education, or library services to children under the age of 18, if the services are
funded by Federal programs either directly or through State or local governments, by Federal
grant, contract, loan, or loan guarantee. The law does not apply to children’s services provided
in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of
facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions
ofthe law may result in the imposition of a civil monetary penalty of up to $1000 per day
and/or the imposition of an administrative compliance order on the responsible entity by
signing and submitting this application the applicant/grantee certifies that it will comply with
the requirements of the Act.
The applicant/grantee further agrees that it will require the language of this certification be
included in any subawards which contain provisions for the children’s services and that all
subgrantees shall certify accordingly.
 By checking this box, the State CSBG authorized official is providing the certification set out
above.
End of Document

SFY-18-L Attachment #1A
DAAS/CAPS Policy Clarification
CSBG Organizational Standards Implementation and Assessment Policy and Procedure
In cooperation with the Community Action Network, DAAS/CAPS has drafted a proposed policy and
procedure to evaluate the State policy and process for assessing CAA’s Compliance with Organizational
Standards. See also Section 6.4a of the CSBG State Plan.
In SFYs 2017 and 2018
a. DAAS/CAPS will perform desk reviews of all eligible entities to assess current
compliance/implementation status and provide a summary of requirements and documentation
needed to comply within 30 days of the review.
b. Eligible entities scheduled for monitoring visits, DAAS/CAPS will discuss results of desk reviews
with eligible entities at scheduled monitoring visits.
c. All eligible entities are expected to be in compliance with the CSBG Organizational Standards by
the end of SFY 2018.
d. For agencies with unmet standards, technical assistance will be provided and tracked in the
agreed upon Organizational Standards Assessment Tool. A summary of the unmet standards is
provided in the Report of Findings document, as applicable.
1. Review cycle per the Calendar of Required Actions once a standard is met.
In SFYs 2019 and going forward
a. DAAS/CAPS will include formal assessment for compliance with Organizational Standards in the
State On-site Monitoring Schedules beginning in SFY 2019.
b. All eligible entities will be reviewed annually for compliance with the applicable CSBG
Organizational Standards either by desk review, or a scheduled on-site monitoring visit.
i. To reduce administrative burden on DAAS/CAPS and eligible entities, following full
implementation and/or compliance, standards without a prescribed a review cycle timeframe
in the “Calendar of Scheduled Actions” listed as “Maintain” or “As Needed/More Frequently
than Annually”, will be reviewed annually only if associated with another regulatory,
statutory, or contractual process that is an annual, or more frequent than annual. Otherwise,
these will be assessed every two years at scheduled monitoring onsite visits. See Exhibit A.
c. Standards listed in the Calendar of Required Actions to be reviewed at 3 or 5 year intervals, will
be reviewed at the next onsite monitoring following the respective 3 or 5-year anniversary dates
the last review.
d. DAAS/CAPS will notify eligible entities of when desk reviews will, prior to making any requests
for information.
e. DAAS/CAPS will not request eligible entities to provide documents that are already on file.
However, DAAS/CAPS will request references and/or citations that indicate specific dates or
1789 W. Jefferson, S/C 010A, Phoenix, AZ 85007  P.O. Box 6123, Phoenix, AZ 85005
Telephone (602) 542-5678  Fax (602) 542-5339  www.azdes.gov

CSBG Organizational Standards – Policy Clarification Rev 8/29/2016
sections of documents where evidence of compliance is to be found, such as specific dates of
meeting minutes, links to online information, or identification of relevant section of bylaws or
policies. Eligible entities are encouraged to conduct self-assessments annually and will be
requested to conduct self-assessments in preparation for on-site monitoring using the agreed
upon assessment tool.
f. Formal and informal findings for Organizational Standards are as follows:
i. The State CSBG Office will not make formal findings regarding Organizational Standards
that are not;
a. existing State or federal statutory or regulatory requirements, or
b. State specified administrative or programmatic requirements in contract scope of
work. The State CSBG Office will instead work with the agency to provide or secure on
their behalf, any needed technical assistance to achieve compliance with any unmet
Standards.
c. These items will be noted as a recommendation in the Report of Findings.
ii. When formal findings are noted DAAS/CAPS will indicate the item in the Report of Finding
with a prescribed date for resolution.
NOTE: This policy applies only to the implementation and compliance with the CSBG Organizational
Standards. All contractual, fiscal, programmatic, statutory, administrative and fiscal
requirements that apply to DAAS/CAPS contracts will continue to be subject to findings and
recommendations.
iii. Existing programmatic, contractual or statutory requirements that may, or may not,
intersect with Organizational Standards, for CSBG or other contracted programs, will still
be subject to formal findings.
Exhibit list –
A. The Community Action Partnership Calendar of Required Actions, a checklist created by the
Community Action Partnership that divides the Organizational Standards by frequency of
required actions (ongoing, annually, every 2 years, etc.).
B. Summary of Requested documents (blank)
_____________________________________________________________________________________________
1717 W. Jefferson, S/C 010A, Phoenix, AZ 85007  P.O. Box 6123, Phoenix, AZ 85005
Telephone (602) 542-5678  Fax (602) 542-5339  www.azdes.gov

SFY-18-L Attachment #2
Corresponding Section New
Model Plan
Proposed Plan Modifications – Detail and Remarks for CAP Network’s 2017 historical comments and space for DES Response/changes and tracking of workgroup discussion
upcoming FFY 2018 in bold text FFY 2018 remarks going forward
Form SF-424M – CSB Model • Proposed narrative or changes listed in this column, • Comments provided in workgroup going forward will be The comments below in small font are from SFY 2017 and included
Plan Template form OMB 0970- dated and annotated. listed here in bold. for historical reference.
0382 • Agreed upon changes will be transferred to the final • Historical Comments are in small font.
matrix document. • New comments, remarks, suggestions and requested
• Historical narrative text (FFY 2017) is in small font. can be typed here in this column in the line associated
• Items requiring updating for FFY 2018 are marked and with the appropriate section.
highlighted as follows: MUST UPDATE FOR FFY 2018 • Additional lines may be inserted at the bottom of this
form for items not appearing here, that the Network
would like to discuss at future
General FFY 2018: 11/7/16: All instances of the abbreviation FFY 2018:
“DAAS/CAPS”, indicating the State CSBG work unit, in
the document will be changed to “State CSBG Office”.
This change will be explained in a narrative in Section
1.
DES will need to update its attached agency policy
documents, as some of these may have changed
during FFY 2016 and 2017. 2/2017: OCS instructions
and comment boxes removed from draft to save space.
Section 1 11/7/16 - Changes in divisional structure will need to
Stated here. 2/2017: Updated with administrative name
changes FOR FFY 2018
Section 2 – State Legislation 11/1/16 – This Section will not change. 2/14/17
and Regulation Confirmed. No changes
Section 3 - State Plan 3.1 and 3.2– Narrative text derived in part from existing FFY 2018: This will be a topic for the 2019 Plan. Goals for Community Action
Development and Statewide language from the previous Plan, Section V. A. 1. The Network would like the State to develop goals for should be drawn from needs assessment. Common areas of
Goals Paragraph (a); and also from language paraphrased from Community Action statewide / at the state level. This may concern should be addressed by DAAS and the Network, as should
the DES webpage. Also under this section: 3.2, State Plan need to be deferred to the new plan that will be drafted in local and State resources available, in order to develop statewide
Goals, with language derived from the previous Plan 2018. goals for Goals. The following verbiage added: For this
Section V. C. Item 3.3a through 3.5 are new, and will likely amendment: DAAS/CAPS, in response to Network input, and in
be discussed at length with the Network. Revisions coordination with the Network, will utilize SFY 2018 to further develop
expected for the SFY 2018 amendment. statewide goals for Community Action. That discussion will include
3/17/2017 1:24 PM 1

SFY-18-L Attachment #2
enhanced communication and technical assistance initiatives;
Comment - 10/31/16: This section will need to be revised broader area assessment strategies, robust data collection, sharing
and strengthened for FFY 2018 in response to the Network and analysis; coordination among statewide agencies and programs,
feedback. Updated with programmatic changes for the and evaluation and improvement of state processes. DAAS/CAPS,
division. Some narrative text from the DES website was will rewrite this planning section for the FFYs 2019-2020 CSBG State
removed. Plan. Programmatic changes include the addition and modification of
programs administered by DAAS. Hunger Prevention and
Independent Living program name change to Aging and Disability
Services added.
Section 3 – State Plan 2/2017: 3.2: text added: “For this amendment: 2018
Development DAAS/CAPS, in response to Network input, and in
coordination with the Network, will utilize SFY 2018 to further
develop statewide goals for Community Action, that
discussion will include enhanced communication and
technical assistance initiatives; broader area assessment
strategies, robust data collection, sharing and analysis, and
coordination among statewide agencies and programs and
evaluation of state processes and DAAS/CAPS will rewrite
this planning section for the FFYs 2019-2020 CSBG State
Plan.”
Section 3 – State Plan 2/2017 The following added to 3.3b. “Other” checkbox 2018
Development checked to indicate consultation with a third party regarding
the funding formula, and 3.4a was revised to add narrative
to describe the process for revising the funding formula.
Section 3 – State Plan 2/2018: 3.4 - Text Added - “For this amendment: 2018
Development DAAS/CAPS distributed a matrix of proposed changes and
updates for the FFY 2018 amendment to the Network in
November 2016 and solicited input. In SFY 2016 and 2017,
DAAS/CAPS engaged a third party consultancy and
facilitated a workgroup with the Arizona Community Action
Agency (ACAA) and the Network to implement a new funding
formula for CSBG, and other DAAS/CAPS administered
programs. As a result, the funding formula was revised based
using factors agreed upon by the Network DAAS/CAPS
distributed a matrix of proposed changes and updates for the
FFY 2018 amendment to the Network in November 2016 and
solicited input. A draft amendment for Network comment was
distributed in February 2017, for comment. Following
meetings and discussion, DAAS/CAPS published the draft
amendment for public inspection to its website in May 2017,
and conducted one public hearing in June [ ], 2017.
DAAS/CAPS also conducted a legislative hearing in August,
2017.”
Section 3 – State Plan 2/2017 3.4b “For this amendment, DAAS/CAPS has revised
Development this two-year plan for FFY 2018. DAAS/CAPS has, in
consultation with the Network, reviewed funding formula
3/17/2017 1:24 PM 2

SFY-18-L Attachment #2
factors for CSBG, and sought input from the Network to
update funding distribution, strengthen narrative sections,
update and clarify monitoring activities and revise CSBG
Organizational Standards implementation policy. in SFY
2017, DAAS/CAPS began discussions with the network
earlier in the grant cycle, and offered additional time for input
and inspection. Section 3.5 below was revised to reflect
guidance from OCS and NASCSP regarding expectations for
growth in this score.”
Section 3 - State Plan FFY 2017 - 3.5 Eligible Entity Overall Satisfaction: Provide FFY 2017 - The Network supports the goal of a 75% overall FFY 2017 - DAAS/CAPS will develop narrative remarks for this State
Development and Statewide the State’s target for eligible entity. Overall Satisfaction satisfaction rate; up from 56% currently. The Network also Accountability Measure for the FFY 2018 Amendment.
Goals during the performance period: requests the inclusion of the survey results (both the overall
score and the score in each of the 9 survey categories) in There is no space for narrative remarks in Section 3.5 of the Model
10/31/16: This section will need to be revised and this document as they are now available. In addition, if Plan. The Survey results are considered confidential and not public
strengthened for FFY 2018. OCS has indicated in a appropriate, the Network would like DES to comment on information, and will not be included with the OLDC submitted State
recent training, that a goal of 10% improvement in ASCI addressing the State Accountability Measure as it relates to Plan. However, for historical and Network coordination purposes,
scores is realistic. This goal should be adjusted to 67% survey scores. they are on record at the DAAS/CAPS office for review.
from 75% for FFY 2018. FFY 2018: DAAS/CAPS revised the 75% overall satisfaction goal to 67%
following guidance from OCS suggesting states aim for a 10%
improve in survey scores.
Section 4 - CSBG Hearing Section III of the previous Model Plan is now contained in FFY 2017- In conjunction with the designated CAP Agencies FFY 2017: Dates updated. Response 1. Hearings are advertised per
Requirements Section 4. See Subsections 4.1-4.3. Hearing dates and the Arizona Community Action Association, there is a State Public Information Office guidelines, on the agency web page.
updated, and next legislative hearing forecast. need to better advertise the State Plan Hearings to Eligible entities and the Arizona Community Action Association may
stakeholders and community partners. also advertise the public hearings. DAAS/CAPS suggest further
Comment -10/31/16: Hearing date(s) need to be FFY 2018: discussion regarding additional means to advertise public hearings in
scheduled. Also, a legislative hearing will need to be the areas where hearings are held as part of the ongoing
scheduled for summer 2017. The current means and communications plan development. 7/11/16 – in response to the
methods for advertising upcoming public hearings may Network comment regarding better advertising for public hearings:
be discussed. DAAS/CAPS now advertises the CSBG public hearings via social
media in addition to the DES webpage.
Section 5 – CSBG Eligible 11/1/16 - This section will not change.
Entitles
Section 6 - Organizational 6.3 – DAAS/CAPS will draft a written policy clarification The Network expressed concern with the timing of all Policy clarification document in process. 7/11/16: Added a check to
Standards for Eligible Entities document in SFY 2017 to clarify the timing at which all eligible entities reaching compliance status (see detailed the box for “Policy” regarding organizational standards assessment,
eligible entities will be expected to be in compliance with all comment below in section 6.4 on the next line). and the narrative edited to add detail to the description of the policy
Organizational Standards, and when “hard monitoring” for FFY 2018: development process.
full compliance will begin” FFY 2018: We will revisit this The Network still has concerns about the timeline (full
policy if needed. Any significant revisions should be compliance by SFY 2018) since agencies recently
done for FFY 2019 monitored have not yet received notification of deficiencies
and no TA plans have been developed. The Network
2/2017 6.3 – Text added: “ For this amendment: Through would like to recommend changing the target date for
discussion with the Network in SFY 2017, DAAS/CAPS full compliance to SFY 2019. The two-year monitoring
3/17/2017 1:24 PM 3

SFY-18-L Attachment #2
agreed that a written policy clarification will need to be requirement for DES will mean that some agencies
developed a policy to facilitate implementation and assess monitored in 2015 will need to be monitored again in the fall
ongoing compliance with the Standards going forward. This of 2017, not allowing enough time to correct deficiencies,
item will be amended for FFY 2018 to reflect especially if TA is needed first. There was a plan that DES
enhancements. DAAS/CAPS engaged a third party submitted to OCS, and the Network would request that
consultant in SFY 2017to evaluate the State Office policies, DES/DAAS develop a process for moving forward,
processes, and the assessments of eligible entities. implement this plan and possibly make changes to the
plan.
2/2017: See policy draft Attachment 6.4
Section 6 - Organizational 6.4 - Organizational Standards for Eligible Entities See There is concern by the Network about the adoption of the Policy clarification is being drafted and will be released in July 2016.
Standards for Eligible Entities attachment 6.4a Narrative updated for FFY 2017. Organizational Standards through contracts with eligible Will remove language from OLDC document, and include instead in
entities. The process that DES has laid out is that in FY16 Attachment 6.4a. The revised text is too long for character limits in the
FFY 2018: half of the agencies will be monitored/assessed and the Online Data Collection System (OLDC). DAAS/CAPS do not have
additional half will be monitored/assessed in FY 17. This plans to utilize third party assessment at this time. 7/11/16: Added a
monitoring/assessment will result in recommendations but check to the box for “Other” regarding organizational standards
no findings. Agencies will be expected to address assessment, to indicate the bi-annual desk review that will take place
deficiencies in order to come into full compliance in FY18. If between onsite monitoring visits. Attachment 6.4 will constitute a draft
this process is held to, there is significant concern about policy clarification following discussion with the Network in late July,
how DAAS can contractually require all agencies to be in 2016. DAAS/CAPS will complete initial State assessments in SFY
compliance with the Organizational Standards. If for 2017. Eligible entities will be required to be in full compliance by SFY
example, an agency is monitored/assessed in FY17 and 2018, as stated in the FFYs 2017-2018 Plan. Beginning in SFY 2017,
there is an Organizational Standard that they are not eligible entities will be assessed via desk review in the year following
meeting and they plan to come into compliance by FY18 an onsite monitoring visit. In SFY’s 2017 and 2018, eligible entities
through training and technical assistance are they out of found not in compliance with the organizational standards will be
contract compliance? Clarity is needed on this issue and it placed on a Technical Assistance Plan. DAAS/CAPS will begin formal
is the recommendation of the Network that a policy is monitoring for compliance with the organizational standards for SFY
issued for FY17. It is requested that this policy 2018, in SFY 2019.
comprehensively outline a uniform process that will be
utilized to determine whether agencies are meeting the FORFFY 2018 – Policy
Organizational Standards.
There is request for clarification on how the state of third
party has or will validate the results of the self-
assessments.
FFY 2018:
Regarding comments in the change matrix, the Network
feels more clarity is needed. How will agencies that were
monitored be notified of deficiencies? How and when will a
plan with timeline be developed to address deficiencies?
The DES response in the change matrix (third column) says
“in SFY 17 and 18, entities found not in compliance will
placed on a Technical Assistance Plan” – this has not
happened. This will make it hard for agencies to achieve
compliance.
The Network reviewed the draft policy on monitoring and is
requesting an updated version. The text that was shared
still lists a separate TAP tool. The Network also had the
following questions: Can a desk review result in findings?
3/17/2017 1:24 PM 4

SFY-18-L Attachment #2
Has the final monitoring tool been identified and/or have
there been changes to the tool? The draft policy states
there will not be findings but then goes in to define findings.
It needs to be clarified what can result in a finding (vs. a
deficiency) and starting when.
Section 6 - Organizational FFY 2017 - Network Comments – Section 6.6 FFY 2017 - 7/25/16- this amount was changed to 75% as the OLDC
Standards for Eligible Entities 11/1/16 - This item may change in the OLDC system. Similar to the comment outlined above, the Network is system would not accept/validate 0% in the field. This line item is
We should revisit after the 1st of the year. concerned about the inclusion in this State Plan that 100% under consideration by OMB as part of the Annual Report draft
of agencies will meet ALL Organizational Standards when documents. Among members of the national Network, this item is a
they are still in the process of being monitored/assessed for point of controversy. DAAS/CAPS will coordinate with the Network in
full compliance. This might be a reasonable expectation for SFY 2017 to come to agreement on the percentage to be listed here,
FY 18 but currently seems out of alignment with the process after the OMB clearance process is completed and it is known if this
being followed. line item is to be maintained or revised. DAAS/CAPS informed the
FFY 2018 Arizona Community Action Network of this issue and solicited
[this item may still require input from the Network] comment. No comments were provided. This may be updated in the
development year for SFY 2019.
Section 7 - State Use of Funds 7.1 indicates the funding formula type by a multiple choice FFY 2018: To be updated
checkbox. The current funding formula description is
included in a separate document, Attachment 3A, Funding
Formula, drawn from the previous Plan and data source
updates, DES has previously provided OCS with this
information in the CSBG IS Report. Item 7.2 indicates
planned allocations to eligible entities for FFYs 2017 and
2018. Attachment 3 is a copy of the CSBG March Alert
indicating DES communication of planned allocations for
SFY 2017 to the Community Action Network. The totals
auto populate. 7.3-7.4 describe the distribution process and
timeframe. This is new text, not included in previous plans.
Item 7.5 asks the State to describe any improvements It
made to the grant and/or contract administration process
from previous State Plans that were the result of feedback
from the Community Action Network (CAN), OCS, etc. DES
gives a brief description of the Government Transformation
and lean initiative project underway. Going forward, this
item will prompt DES to obtain feedback from the above
mentioned sources and determine if performance
management adjustments are necessary.
2/2017 – Funding formula revised. See attachment.
11/1/16 – Per the last paragraph, this item will be
discussed in workgroup for FFY 2018. MAY UPDATE
FOR FFY 2018 PENDING FUNDING FORMULA
DISCUSSION (LIKELY)
Section 7 - State Use of Funds 7.2. Allocations updated using March 2016 Alert numbers. FFY 2018: To be updated
No other changes. Source: FFYs 2015-2016 CSBG State
Plan Amended, FFYs 2015-2016, Section V.3.
3/17/2017 1:24 PM 5

SFY-18-L Attachment #2
FFY 2018: MUST UPDATE FOR FFY 2018. This item will
be updated with initial allocation numbers typically
announced in the March Alert. If the funding formula
changes prior to determining FFY 2018 allocations, will
convey these changes in this attachment.
2/2017: Will update – numbers pending.
Section 7 - State Use of Funds 7.3. Narrative updated for FFY 2017. See Attachment 3, FFY 2017 - 7/7/16: Public Hearing: Coconino County 7/20/16: DAAS/CAPS acknowledges the comments and will indicate
FFY 2017 Funding Formula. Information derived from the Community Services Department – “With all the economic in the State Plan under Section 7.5 - Performance Management
FFY 2016 State Plan Amendment document, Section V. B. background provided at the beginning of our comments, Adjustment, the following: “In SFY 2016, DAAS/CAPS and the
Note: The source for the unemployment factor has been Coconino County is very grateful that the Arizona Network initiated a workgroup project to evaluate the funding
changed from the Arizona Department of Administration Department of Security is undertaking a thorough distribution formula factors. In SFY 2017, DAAS/CAPS engaged a
Unemployment Statistics Program Special Unemployment evaluation of the current funding distribution formula, that consultant to conduct research and report to the group best practices
Report to the most recent annual Local Area which is described in Attachment 3A, and in Section 7 of the utilized by other states, and additional data sources that may be of
Unemployment Survey (LAUS). Text tweaked for format Plan . We strongly recommend that the Cost of Living Index use in an updated formula. DAAS/CAPS will provide an update to
compatible with OLDC. become a part of further funding formulas. the funding formula discussion in the amendment for FFY 2018.”
FFY 2018: FFY 2018
Section 7 – State Use of Funds 7.3-7.4 – Distribution processes and timeframe. See new FFY 2018: 7.4a – Actual verbiage/new in bold: For this amendment: The
7.4 and 7.4 narrative text added. Item 7.5: “Performance management Network comments: OCS had asked about the fiscal year State operates on a State Fiscal Year. Funds allocated to eligible
adjustment:” asks DES to describe any and availability of funds. DES provided a description of the entities are made available for obligation on the first day of the
changes/improvements made to “grant and/or contract process, but does not seem to address the 30-day issue. State Fiscal Year. Funds are disbursed on a cost reimbursement
administration procedures” from previous Plans. New The Network would like to request that DES provide actual basis. Eligible entities annually submit a proposed Itemized Service
narrative added. No corresponding item in previous Model draft language for the Network to review. Budget (ISB) document, for detailing allowable expenditures for
Plans. activities included in the agency’s CAP Plan. Eligible entities invoice
2/2017: the State on a monthly basis for these allowable expenditures under
11/1/16: 7.4 SHOULD UPDATE FOR FFY 2018. CSBG. Invoices are due on the 25th of each month. Larger public
Availability of funds: NEW verbiage proposed in FFY entities may be allowed to invoice semi-monthly upon DAAS/CAPS
2018. OCS accepted the current verbiage, but noted approval. Invoices must include backup documentation for
with remarks the description of the availability of funds. expenditures billed. DAAS/CAPS is bound by contract with the
In light of the fact OCS found this language unclear, eligible entities to make payments on approved invoices within 30
CSBG Program suggests revising this verbiage for days.
clarity. The following is OCS’s remark: “7.4 State Payments on invoices may be delayed temporarily pending the
operates on a July-June FY and an invoice submission of past-due contract deliverables, such as Community
reimbursement system so funds are not made available Action Plan documents or required reports, or for incomplete
to EE's w/in 30 days.” documentation.
CSBG Program staff will confer with fiscal and contract
personnel to ensure that the description of distribution
of funds clearly describes the way funds are made
available.
----------------------------------------------
Facts for discussion about the State CSBG Office
process for making CSBG funds available:
Arizona uses a cost reimbursement model to
disburse CSBG and other funds. The State
allocates and makes available funding to the
3/17/2017 1:24 PM 6

SFY-18-L Attachment #2
CAAs, using funding formulas with variables
as follows:
• The State includes CSBG and LIHEAP, as
well as TANF, and several other funds as
components of the Community Action
Program and Services contract.
• The available funding is forecast in
advance of the new State fiscal year (July-
June). The allocations forecast is based
upon the previous year’s funding, and
estimated funding available is
communicated to the network in a bulletin,
officially called an “Alert”. These are
usually issued in March, prior to the start
of the State fiscal year.
• Contracts are issued shortly thereafter,
signed and returned prior to July 1.
• CAAs may bill against the initial allocation
if they have returned their signed
contracts, and the new fiscal year has
begun.
• If actual funding amounts change, the
State issues a new bulletin, and amends
the contracts.
• Carryover is determined, and made
available via another Alert, and a
subsequent contract amendment occurs
in August or September.
• Agencies provide an itemized service
budget (ISB), with their annual application
for funds. Then, they bill monthly for all
direct and indirect expenditures for
allowable activities conducted under the
contract, in accordance with their ISB.
• Larger agencies may be allowed to issue
“supplemental” billings during a month in
peak demand periods, in addition to
regular scheduled invoicing.
Section 7 – State Use of Funds 11/9/16: This section may change depending upon the FFY 2018:
7.7 distribution of State administrative funds and any State
personnel changes that will be in effect for FFY 2018.
MUST UPDATE FOR FFY 2018
2/017 – updates pending
3/17/2017 1:24 PM 7

SFY-18-L Attachment #2
Section 7 – State Use of Funds 7.9-7.10. Discretionary award amounts updated in table The Network is requesting that DAAS outline what is done The CSBG Discretionary funds allocated for emergencies and
and Section 8 State Training provided by OCS. Narrative consists of a description of with the discretionary CSBG dollars if they go unspent disasters are $30,000, in addition to the $88,820 allocated for special
and Technical Assistance awards given in the past year. Item 7.11 checkboxes to within a given fiscal year? projects. There is no option to attach the allocations document in this
7.9-7.11 indicate the type of organizations receiving discretionary The Network would like clarification on whether there is a area of the Plan in OLDC. Attachment 3 addresses the unspent funds,
funds. The 7.11 information is usually reported on the separate set aside for unforeseen emergencies or is this and a narrative was added to address the carryover funds for special
annual CSBG IS Report. CSBG Program recommends included in the $88,820? projects and emergencies. 7/11/16: DAAS/CAPS has further stipulated
adding verbiage indicating the plan for unspent that CSBG discretionary funds allocated for special projects ($88,820)
discretionary funds. Section Item 8.1. Training and FFY 2018: that are not awarded for the upcoming SFY, will be made available for
Technical Assistance (T/TA), derived from previous (FFY The Network requests inclusion of more information about emergencies and disasters in addition to the $30,000 allocated for this
2016 Amendment) Plan, Section, D. Section 8 (T/TA) is the disposition of unused discretionary funds. Will unused purpose. New text: CSBG discretionary awards for SFY 2017
referred to here as DES uses discretionary funds to provide funds be carried over as discretionary funds? Will they be described.
training and technical assistance. Relevant dates updated. redistributed based on the funding formula? 2/2017:
Maricopa County discretionary narrative will be updated to Regarding Special Projects funds: Text Added: If all funds are not
describe current use of carryover discretionary funds. awarded during the current fiscal year, these funds may be used for
Source for DAAS narrative: FFYs 2015-2016 CSBG State emergencies and disasters should the need arise during said year.
Plan Amended, Section V., Section V. D., FFYs, 2015- Remaining unobligated funds will be carried over to the next grant year,
2016. and redistributed with the 90 percent funds allocated to eligible entities.
11/9/16: SHOULD UPDATE FOR FFY 2018 CSBG
Program suggests reviewing verbiage in this area relative to
any CSBG Discretionary funds carried over, and any Regarding Emergencies : Emergencies
special projects funds not awarded during the applicable See Attachment 3 Allocations 2017. Unobligated funds from the
fiscal year. Currently, this is covered in the Attachment 3, current plan year will be carried over to the next grant year, and
“Allocations 2017”. CSBG Program further suggests adding redistributed with the 90 percent funds allocated to eligible entities.
this verbiage to the front end of the plan document in
Section 7.11, instead of an attachment.
2/2017 - updated
Section – 8 8.1 Sources: CSBG State Plan Document, Section V. D., Network Comments – Section 8.1 Items of concern from the Network added, such as those addressing
State Training and Technical FFYs, 2015-2016, Amended for FFY 2016 and FFY 2016 In addition to the topics outlined above, the Network ROMA Next Gen, CAP Plans and Self-Sufficiency Matrix.
Assistance form SF-424. OCS requests a description of the State’s requests inclusion of the following training priorities: DAAS/CAPS and the Arizona Community Action Association will
technical assistance plan with timeframes. 1. ROMA Next Generation continue to coordinate and agree upon topics and adjust schedules
See also Section 8.4 of the State Plan document. 2. Creating and implementing a meaningful CAP Plan for SFYs 2017 and 2018.
FFY 2018: MUST UPDATE FOR FFY 2018 and include 2018
narrative describing our current coordination efforts for 3. Evidenced Based, High Impact, Outcome Driven 7/11/16: DAAS/CAPS will work to develop and deliver case
TTA going forward. Programing – ROMA NEXT management training in SFY 2017. The CSBG Plan Training and
4. Technical Assistance on using the Self Sufficiency Technical Plan draft contains a line item for “Program Delivery” to be
Matrix to track client outcomes delivered in FFY1 – Q3. This training has the DAAS/CAPS case
7/6/16: Pima County Community Services Department management component.
commented requesting case management training be added Section 8.2 applies to the CSBG organizational standards. Narrative
to the training and technical assistance schedule. Pima related to other training and technical assistance is moved to 8.4.
County also requested clarification to section 8.2.
2/2017 - DAAS/CAPS is working with ACAA in SFY 2017 to
FFY 2018: develop a concrete technical assistance plan.
The Network is requesting an actual TTA plan, if necessary
action steps to develop such a plan, deadlines and
explanation who would provide the TTA .
The Network would like to see a plan that shows the State’s
responsibility for TTA as distinct from ACAA activities.
3/17/2017 1:24 PM 8

SFY-18-L Attachment #2
DAAS should also indicate how they identified the
categories for TTA, e.g. due to monitoring. The Network
would like to suggest a thorough needs assessment (in
addition to the ACAA survey already completed).
Section – 8 8.2 Technical Assistance Plan Network Comments – Section 8 Section 8.2 changed to “no”. DAAS/CAPS is developing a tool for
State Training and Technical The Network is not aware of the Technical Assistance Plan creating a TAP for eligible entities with unmet Organizational
Assistance FFY 2018: MUST UPDATE FOR FFY 2018. TAP Plan has or Quality Improvement Plan Section 8.2 indicates is in Standards which it is testing for workability during the State
been incorporated into existing monitoring tools. place. The Network is requesting the opportunity to review Assessment period. 7/11/16: A draft copy of a proposed Technical
this document. Assistance Plan tool has been distributed to the Network for
2/2017 Text added: “to facilitate agencies implementing review and comment.
and attaining compliance. DAAS will track unmet standards, FFY 2018: 2/2017
needed documentation, time-bound objectives toward Technical Assistance will be tracked using the CSBG Organizational
compliance via the DAAS Contracts Report of Findings Standards Monitoring Tool, and the existing Report of Findings tool.
(ROF) document. DAAS/CAPS will use this document to The proposed TAP Tool draft was discontinued. References to a
provide a summary of the State assessment. Standards formal TAP tool were removed.
that are unmet, or met but needing documentation, or
currently implementing, will be listed as Recommendations,
and summarized with requested actions and due dates.
SECTION 9 9.1-9.2 – State Linkages and Communication “The Network requests that significant modifications be No changes were made at this time. This language was carried over
State Linkages and made to this section. The Network thinks it is crucial that the from FFYs 2015-2016 CSBG State Plan document.
Communication FFY 2018: To be discussed. May be redesigned for FFY State (DAAS) be creating linkages with those listed above
2019, plan development year. in addition to- DAAS/CAPS has begun conversations with some of the
1. Head Start organizations/agency divisions operating the programs listed in
2. Public Health Section 9 and in the Network comments. DAAS/CAPS will discuss
3. Child Welfare with the Network in SFY 2017 and update this Section in the FFY18
4. Aging plan submittal. 7/11/16: 9.1 The State WIOA office was included in
5. Faith Based Organizations the checkboxes in this section of the Plan. The State Plan document
6. Educational Institutions is revised to clarify State role in making federal assurances regarding
The Network is requesting that DAAS utilize section 9.2 to linkages and communication. Enhanced responses related to
outline how they are planning on coordinating with these Section 9 questions are added to the OLDC document and removed
entities.” from Attachment 4. Attachment 4 will contain only program narrative
material derived from submittals from CAAs to serve as examples of
7/7/16: Network comment - Coconino Community Services assurances stated in Section 14. Added to 9.2: “DAAS/CAPS will
Department –“ WIOA was not included in the list of continue its conversations with the State WIOA office in SFY 2017.
programs with which the State needs to make a direct DAAS/CAPS will investigate opportunities to coordinate and/or
connection and create a collaborative process for service to exchange information with the State offices of Head Start (Education
families throughout the State. Community Action Agencies Department), Public Health, and Child Welfare. DAAS/CAPS CSBG
were specifically cited in the Workforce Investment program staff participate in the activities of the DES Office of
Opportunity Act as Partners. We encourage the State of Community Engagement, which is at this time engaging the Child
Arizona to move swiftly, with our input, to develop a Support Services Office in an effort to link non-custodial parents with
meaningful plan to address how the State will be integrating services that may better enable them to meet child support
program areas and goals, as well as creating a nexus for obligations. DAAS/CAPS provides CSBG discretionary funding to
the agencies to do so as well.” Pima County Community ACAA (State Association) to provide coordination among programs.
Services Department also commented, requesting DAAS/CAPS will discuss further with the Network a plan for
clarification on this item. coordination of program activities with other State agencies in SFY
2017.
3/17/2017 1:24 PM 9

SFY-18-L Attachment #2
FFY 2018
The Network would like more specifics on how linkages at
the State level are created, describing goals for the
linkages, a work plan, and an explanation what the impact
is, what NPIs are affected, and how the relationships benefit
the Network.
This section can build on the CAP plans where CAAs report
on their linkages, but the State should describe state-level
activities. An example that was suggested previously was
building relationships with WIOA/Arizona@Work.
DES/DAAS could use language from the IM on coordinating
community action with workforce programs. The plan can
build on local activities (e.g. x number of CAAs are doing
xyz with workforce) and then state what the State is doing
to support those activities.
SECTION 10 10.1. Section requests detail regarding monitoring and The Network is requesting clarity on the Full onsite review In response to the comment regarding full on-site review in Section
Monitoring, Corrective Action, monitoring reports not requested in the previous plan in relation to the Organizational Standards. Is the plan to 10.1, see Attachment 6.4a. The Technical Assistance Plan document
and Fiscal Controls model, including a monitoring schedule and the inclusion of exempt Organizational Standard compliance from this is in draft form and will be shared and discussed with the Network
written monitoring policies. Section 6 contains detailed review until FY18? prior to finalization and formal utilization.
information regarding monitoring. ACAA - Again, the Network is requesting access to the 7/11/16: The State Plan indicates agencies are expected to reach full
10.4a. Technical Assistance Plan document as no one is currently implementation by SFY 2018. Eligible entities assessed during
10.6 Reporting of QIPs: DAAS CAPS does not currently utilizing one to ensure they are coming into compliance with onsite monitoring in SFY 2016 and 2017 will be assessed by desk
report eligible entities on QIP’s, or Corrective Improvement Organizational Standards by 2018. review in SFYs 2017 and 2018, respectively. DAAS/CAPS will still be
Plans (CIPs), to OCS in DAAS/CAPS terminology. performing initial State assessments in SFY 2017. However, the
Organizational Standards are still in the implementation FFY 2018: State Plan, and the policy document in development, will indicate
phase and eligible entities found deficient will be offered See comments above on section 6.4. The Network is DAAS/CAPS will not begin to make formal monitoring findings with
technical assistance as appropriate at this time. requesting an updated policy and clear communication on respect to organizational standards compliance status until SFY
any deficiencies or findings. 2019, in accordance with the State monitoring schedule. Currently,
FFY 2018: SHOULD UPDATE FOR FFY 2018 TAP Plan is DAAS/CAPS solicits a Corrective Improvement Plan (CIP) from the
incorporated into existing monitoring tools; a separate eligible entity and tracks time-bound objectives toward the remedy of
TAP tool will not be used. Must update for FFY 2019. findings and deficiencies. For serious deficiencies, the State Office of
Procurement may issue a demand for assurance to the eligible entity
for findings related to fiscal and administrative Terms and Conditions
of the DAAS/CAPS contract. DAAS/CAPS follows up with the
agency to assure the completion of the CIP, making follow up visits if
necessary and providing technical assistance. DAAS/CAPS is
developing a TAP tool to be used to track technical assistance and
efforts toward compliance with the CSBG organizational standards.
DAAS/CAPS believes it is more appropriate for the State to assist
eligible entities making good faith efforts to comply in achieving
compliance than it is to make findings. A draft TAP tool has been sent
to the Network for review and comment.
SECTION 10 10.9 - From the FFYs 2015-2016 CSBG State Plan
Monitoring, Corrective Action, document Section IV (B)(a)-(e). See also Attachment 7
and Fiscal Controls Scope of Work 2016-2020. Bold text added for clarification.
3/17/2017 1:24 PM 10

SFY-18-L Attachment #2
10/2016 Previous monitoring dates added to the plan
document at the request of OCS.
MUST UPDATE FOR FFY 2018
Section 11 - Eligible Entity FFY 2018: No planned changes
Tripartite Board
Section 12 - Individual and FFY 2018: MUST UPDATE FOR FFY 2018. Updates to FFY 2018:
Community Income Eligibility income thresholds – no other planned changes The Network requests a description be added on the use of
Requirements categorical eligibility. Several CAAs are or will be using it,
and the process and options for utilizing it should be
described in the state plan.
Section 13 - Results Oriented 13.1-13.4 contain checkbox responses and narrative 2017: 7/6/16: Pima County Community Services expressed 7/14/16: Section 13.5 of the CSBG State Plan Draft reads
Management and Accountability regarding ROMA system reporting, and planning processes. a desire to submit a CAP Plan every two years instead of “Submission of a Community Action Plan by the eligible entities is
(ROMA) System FFY 2018: update 13.5 verbiage describing creating a annually. Pima County also expressed a desire for the required by contract at least once every two years, and during the
new CAP Plan model in coordination with the Network State in coordination with the Network, to update the CAP contract renewal period, as part of the eligible entity’s application
in FFY 2018. May fully recast in the FFY 2019 Plan model. package.” DAAS/CAPS will issue a policy clarification on this topic
development FFY 2018: and revise scopes of work to reflect this option. DAAS/CAPS will
The development of the CAP plan and revision of the CAP initiate discussion with the Network in SFY 2017 to develop an
Plan template should be addressed. The description should updated model CAP Plan template that better reflects the Network’s
reflect the language from the org standards and outline a objectives and aligns with the CSBG Organizational Standards.
process and timeline for change. The org standard
monitoring tool (standard 4.2) states that a CAP plan would 13.3-13.4 to be revisited for SFY 2019
be required every three years and lists key components of
the plan. Submission of the plan is currently staggered and
the Network would lke to retain that option since agencies
are aligning their needs assessment and/or plan with other
programs.
SECTION 13 FFY 2018: No planned changes. FFY 2018:
Results Oriented Management
and Accountability (ROMA)
System
Section 14 14.1, Attachment 4, Section 14 Narrative Responses - State 2017: The Network is concerned that Attachment 4 - State Attachment 4 was reworked in response to the Network’s concerns.
CSBG Programmatic Linkages and Communication. Linkages and Communication, does not demonstrate Program narrative text will be reviewed again by the Network, and
Assurances and Information assurances effectively. Example: Assurance that funds are may be revised prior to final submission of the State Plan and/or in
Narrative FFY 2018: Extensive revision and updates needed by used to secure and retain meaningful employment -- the FFY 2018 amendment. Regarding the example provided, it
FFY 2019. "Eligible entities provide employment supports and could be revised as follows: 7/11/16: Section 14 is substantially
coordinate with WIOA programs. Some entities operate revised to clarify the State’s role in making the federal assurances
employment assistance in their own facilities." This answer contained therein. DAAS/CAPS reviewed responses for this Section
doesn't demonstrate how DAAS assures that eligible made by other states and discussed Network concerns and
entities provide employment supports so that funds are suggestions with ACAA, (the State association) prior to making
used to help low-income individuals secure and retain revisions. Responses to Section 14 questions are removed from the
meaningful employment. This is the case throughout Attachment 4, and added to the OLDC document. Responses to
Attachment 4. questions 14.1a and 14.1b are too long to include in the OLDC
7/7/16 Public Hearing Comment: Coconino County document, due to character limitations, and are included as two
Community Services Department – “Increased benefits for separate attachments, Attachments 14.1a and 14.1b. Attachment 4
3/17/2017 1:24 PM 11

SFY-18-L Attachment #2
working poor: there is a reference to increased benefit will contain only program narrative material derived from submittals
levels for applicants reporting income in this section of the from eligible entities to serve as examples of eligible entity activities
plan in Attachment 4, 14.1a 676(b)(1)(A)(i). We believe that related to assurances in Sections 9 and 14. See also Section 9.
the accurate reference here should be the working poor, but Response to 7/7/16 comments: DAAS/CAPS revises 14.1a.(i) to
that is left to interpretation. Therefore, we recommend an read as follows: “(i)The State has authorized increased benefit levels
explanation of the intended meaning.” Pima County also for utility assistance for the “working poor”, defined as applicants
requested clarification on 7/6/16. from households reporting income from employment, self-
FFY 2018: employment/business income, or Unemployment Insurance, who
have incomes that fall below 150% of poverty, and struggle to meet
basic needs. CSBG supported programs such as the State
authorized Short-Term Crisis Services (STCS), funded by
Temporary Assistance for Needy Families (TANF) funds, may
provide for work related expenses such as necessary licensing fees,
uniforms or transportation assistance through CSBG funded
programs. Eligible entities are required by contract to deliver this
program. The State allows eligible entities to use CSBG funds for
these services for childless adults who do not qualify for this service
under TANF rules.
SECTION 14 14.3-14.13 – Program narrative examples. The Network is concerned that Attachment 4 - State Portions of Attachment 4 were reworked in response to the Network’s
CSBG Programmatic Linkages and Communication, does not demonstrate concerns. Please see revised version. Program narrative text will be
Assurances and Information FFY 2018: Narrative material may be updated. This assurances effectively. Example: Assurance that funds are reviewed again by the Network, and may be revised prior to final
Narrative could wait until FFY 2019. used to secure and retain meaningful employment -- "Eligible submission of the State Plan. Regarding the example provided,
entities provide employment supports and coordinate with 14.1a.(ii) in Attachment 4 is revised as follows: “Eligible entities
WIOA programs. Some entities operate employment provide employment support services listed in ROMA NPI 1.2 through
assistance in their own facilities." This answer doesn't the State Short Term Crisis Services Program, and through CSBG
demonstrate how DAAS assures that eligible entities provide funded services. Eligible entities also coordinate with WIOA
employment supports so that funds are used to help low- programs. Some entities operate employment assistance programs in
income individuals secure and retain meaningful their own facilities."
employment. This is the case throughout attachment 4. 7/19/16: Section 14 responses were further revised to clarify the
7/7/16 Public Hearing: Network comment: - Coconino County State’s role. Responses to questions 14.3-14.4 were made in the
Community Services Department – “CSBG Programmatic OLDC document. Program narrative examples of Network activities
Assurances and Information Narrative: the information remain in Attachment 4, renamed “Attachment 4, 2017 Program
included in Attachment 4 of the Plan is a cut and paste of the Narratives”.
information included by the Community Action Agencies in
the plans. It address how Community Action Agencies
coordinate anti-poverty services. However this Section is
silent on the State of Arizona’s responsibilities for the same
program assurances. We recommend the State’s role be
specifically articulated before the Plan is submitted to HHS.”
FFY 2018:
Regarding 14.2. on discretionary funds, please see the
comments from the Network regarding sections 7.9 – 7.11.
3/17/2017 1:24 PM 12

SFY-18-L Attachment #2
Section 15 FFY 2018: This will not change.
Federal Certifications
Additional Comment Space
Section [ ]
Section [ ]
Section [ ]
Section [ ]
3/17/2017 1:24 PM 13

Douglas A. Ducey Henry Darwin
Governor Interim Director
SFY-18-L Attachment #3
Section 7 - CSBG State Plan FFYs 2017-2018 – Funding Formula –and Administrative Budget -
AMENDED
Distribution Formula
The distribution of CSBG funds to eligible entities is based upon the following formula factors:
Migrant/
Poverty Rural Extreme Tribal Seasonal Minimum Funding
Factor Factor Poverty Adjustment Farmworker Variable
Adjustment
90% 5% 5% Yes 2% $150,000
In SFY 2018, eligible entities will be held harmless to 50 percent of any decrease from the previous
state fiscal year resulting from the new funding formula.
• Poverty
Ninety percent of funds are distributed according to the number of persons living at or below
125 percent of poverty in a given geographic area. Tribal households residing on reservations
receiving direct CSBG funds are not included in the calculations. Poverty statistics are obtained
from the most current U.S. Decennial Census data available for the State of Arizona and updated
using the 2010 American Community Survey for 2015 a five-year period (2011-2015).
• Extreme Poverty
Five percent of funds are distributed according to the number of households living at or below
70% of poverty in a given geographic area Tribal households residing on reservations receiving
direct CSBG funds are not included in the calculations. Poverty statistics are obtained from the
most current U.S. Decennial Census data available for the State of Arizona and updated using the
2010 American Community Survey for 2015 a five-year period (2011-2015).
• Unemployment
Ten percent of funds are distributed based upon the unemployment rates in each designated
geographic service area. The source for the unemployment factor is the most recent annual Local
Area Unemployment Survey (LAUS). Unemployment statistics are updated on a yearly basis.
1789 W. Jefferson, Mail Drop 1111, Phoenix, AZ 85007  P.O. Box 6123, Phoenix, AZ 85005
Telephone (602) 542-5757  Fax (602) 542-5339  https://des.az.gov/

• Rural
Five percent of funds are distributed only to rural counties based upon a determination of special
needs such as disproportionately high unemployment, logistical challenges such as availability of
transportation, distances to and from remote areas and disproportionate cost and availability of
energy and other essential services. Rural statistics are obtained from the most current U.S.
Decennial Census data available for the State of Arizona and updated using the 2010 American
Community Survey for a five-year period (2010-2014).
• Tribal Adjustment
In 1982, American Indian Tribes within the State were given the opportunity to apply for funding
directly from the Department of Health and Human Services. The tribes receive approximately
15 to 20 percent of the State’s gross allocation. American Indian populations residing on
reservations receiving separate CSBG allocations are excluded from the funding formula.
• Migrant and Seasonal Farmworker Adjustment
Two percent of funds allocated to eligible entities is reserved for a designated limited purpose
entity serving migrant or seasonal farmworkers and their families statewide.
• Minimum Funding Variable - $150,000
All eligible entities are guaranteed a minimum allocation of $150,000 depending upon availability
of funds.
Agencies will receive a proportional share of any increase or decrease to the State’s
appropriation.
• Administrative Budget
The State will not expend more than the greater of $55,000 or five percent of its allotment under
Section 674 of the Act for administrative expenses, including monitoring activities. Arizona will
not use CSBG funds for Charity Tax Credit Programs. The State maintains accounting procedures
established to assure that the administrative cost limitation is not exceeded. Regular meetings
will be held to discuss the level of expenditures. The State’s Office of Accounting will prepare
monthly reports. In the event that the State does not use the entire five percent of the total
reserved for the ADES administrative expenses, the remainder may also be used to fund
discretionary activities.
The State’s projected administrative budget is as follows:
Administrative Budget – SFY 2018 Amendment 2017 2018
TBD
Personnel $ 121,000
Employee Related Expenses $ 56,000
1789 W. Jefferson, Mail Drop 1111, Phoenix, AZ 85007  P.O. Box 6123, Phoenix, AZ 85005
Telephone (602) 542-5757  Fax (602) 542-5339  https://des.az.gov/

Professional & Outside $ 39,500
Travel In-State $ 3,000
Non-Capital Equipment
Other Operating $ 4,000
Indirect $ 50,320
Total: $ 273,820
1789 W. Jefferson, Mail Drop 1111, Phoenix, AZ 85007  P.O. Box 6123, Phoenix, AZ 85005
Telephone (602) 542-5757  Fax (602) 542-5339  https://des.az.gov/

SFY-18-L Attachment #4
DETAILED MODEL PLAN (LIHEAP)
Program Name: Low Income Home Energy Assistance
Grantee Name: ARIZONA
Report Name: DETAILED MODEL PLAN (LIHEAP)
Report Period: 10/01/2016 to 09/30/2017
Report Status: Submitted
Table of Contents
1. Mandatory Grant Application SF-424 .................................................................................................... 2
2. Section 1 - Program Components ........................................................................................................... 4
3. Section 2 - HEATING ASSISTANCE ...................................................................................................... 8
4. Section 3 - COOLING ASSISTANCE .................................................................................................... 10
5. Section 4 - CRISIS ASSISTANCE ......................................................................................................... 12
6. Section 5 - WEATHERIZATION ASSISTANCE .................................................................................... 15
7. Section 6 - Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A) ............................................................. 17
8. Section 7 - Coordniation, 2605(b)(4) - Assurance 4............................................................................. 18
9. Section 8 - Agency Designation,, 2605(b)(6) - Assurance 6 ................................................................. 19
10. Section 9 - Energy Suppliers,, 2605(b)(7) - Assurance 7 ...................................................................... 21
11. Section 10 - Program, Fiscal Monitoring, and Audit, 2605(b)(10) - Assurance 10 .............................. 22
12. Section 11 - Timely and Meaningful Public Participation, , 2605(b)(12) - Assurance 12, 2605(c)(2) .....
25
13. Section 12 - Fair Hearings,2605(b)(13) - Assurance 13 ....................................................................... 27
14. Section 13 - Reduction of home energy needs,2605(b)(16) - Assurance 16 .......................................... 29
15. Section 14 - Leveraging Incentive Program ,2607A .............................................................................. 30
16. Section 15 - Training ............................................................................................................................. 32
17. Section 16 - Performance Goals and Measures, 2605(b) ...................................................................... 34
18. Section 17 - Program Integrity, 2605(b)(10) ......................................................................................... 35
19. Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility Matters ......... 39
20. Section 19: Certification Regarding Drug-Free Workplace Requirements ........................................... 43
21. Section 20: Certification Regarding Lobbying ...................................................................................... 46
22. Assurances ............................................................................................................................................. 48
23. Plan Attachments ................................................................................................................................... 52
Page 1

SFY-18-L Attachment #4
Mandatory Grant Application SF-424
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
* 1.a. Type of Submission: * 1.b. Frequency: * 1.c. Consolidated * 1.d. Version:
Plan Annual Application/Plan/Funding Request? Initial
Resubmission
Explanation: Revision
Update
2. Date Received: State Use Only:
3. Applicant Identifier:
4a. Federal Entity Identifier: 5. Date Received By State:
4b. Federal Award Identifier: 6. State Application Identifier:
7. APPLICANT INFORMATION
* a. Legal Name: Arizona Department of Economic Security
* b. Employer/Taxpayer Identification Number (EIN/TIN): 86-6004791 * c. Organizational DUNS: 136730434
* d. Address:
* Street 1: 1789 WEST JEFFERSON Street 2: P.O. BOX 6123
* City: PHOENIX County:
* State: AZ Province:
* Country: United States * Zip / Postal Code: 85007 -
e. Organizational Unit:
Department Name: Division Name:
The Division of Aging and Adult Services
f. Name and contact information of person to be contacted on matters involving this application:
Prefix: * First Name: Middle Name: * Last Name:
Tammy Frazee
Suffix: Title: Organizational Affiliation:
Community Action Administrator
* Telephone Fax Number * Email:
Number: (602) 542-6655 tfrazee@azdes.gov
(602)
542-2895
* 8a. TYPE OF APPLICANT:
A: State Government
b. Additional Description:
* 9. Name of Federal Agency:
Catalog of Federal Domestic CFDA Title:
Assistance Number:
10. CFDA Numbers and Titles 93568 Low-Income Home Energy Assistance
11. Descriptive Title of Applicant's Project
LIHEAP State Plan
12. Areas Affected by Funding:
13. CONGRESSIONAL DISTRICTS OF:
* a. Applicant b. Program/Project:
07 Statewide
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SFY-18-L Attachment #4
Attach an additional list of Program/Project Congressional Districts if needed.
14. FUNDING PERIOD: 15. ESTIMATED FUNDING:
a. Start Date: b. End Date: * a. Federal ($): b. Match ($):
10/01/2016 09/30/2017 $0 $0
* 16. IS SUBMISSION SUBJECT TO REVIEW BY STATE UNDER EXECUTIVE ORDER 12372 PROCESS?
a. This submission was made available to the State under the Executive Order 12372
Process for Review on :
b. Program is subject to E.O. 12372 but has not been selected by State for review.
c. Program is not covered by E.O. 12372.
* 17. Is The Applicant Delinquent On Any Federal Debt?
YES
NO
Explanation:
18. By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and
accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that
any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)
**I Agree
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.
18a. Typed or Printed Name and Title of Authorized Certifying Official 18c. Telephone (area code, number and extension)
18d. Email Address
18b. Signature of Authorized Certifying Official 18e. Date Report Submitted (Month, Day, Year)
09/01/2016
Attach supporting documents as specified in agency instructions.
Page 3

SFY-18-L Attachment #4
Section 1 - Program Components
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Department of Health and Human Services
Administration for Children and Families
Office of Community Services
Washington, DC 20447
August 1987, revised 05/92, 02/95, 03/96, 12/98, 11/01
OMB Approval No. 0970-0075
Expiration Date: 02/28/2005
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Use of this model plan is optional. However, the information requested is required in order
to receive a Low Income Home Energy Assistance Program (LIHEAP) grant in years in which the grantee is not permitted to file an abbreviated plan. Public
reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and
maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number.
Section 1 Program Components
Program Components, 2605(a), 2605(b)(1) - Assurance 1, 2605(c)(1)(C)
1.1 Check which components you will operate under the LIHEAP program. Dates of Operation
(Note: You must provide information for each component designated here as requested elsewhere in this plan.)
Start Date End Date
Heating assistance 10/1/2016 09/30/2017
Cooling assistance 10/1/2016 09/30/2017
Crisis assistance 10/1/2016 09/30/2017
Weatherization assistance 10/1/2016 09/30/2017
Provide further explanation for the dates of operation, if necessary
Arizona has identified date ranges for heating and cooling, and has assigned a date range to each county for FFY 2017.
1) HEATING (November 1st - March 31st) and COOLING (April 1st - October 31st) for counties: Coconino, Yavapai, Navajo, Apache, Greenlee, Graham, Cochise, and
Santa Cruz.
2) HEATING (December 1st - March 31st) and COOLING (April 1st - November 30th) for counties: Mohave, La Paz, Yuma, Maricopa, Gila, Pinal, and Pima.
Estimated Funding Allocation, 2604(C), 2605(k)(1), 2605(b)(9), 2605(b)(16) - Assurances 9 and 16
1.2 Estimate what amount of available LIHEAP funds will be used for each component that you will operate: The total of all percentages must add up to Percentage ( % )
100%.
Heating assistance 21.80%
Cooling assistance 41.20%
Crisis assistance 5.00%
Weatherization assistance 15.00%
Carryover to the following federal fiscal year 0.00%
Administrative and planning costs 10.00%
Page 4

SFY-18-L Attachment #4
Services to reduce home energy needs including needs assessment (Assurance 16) 5.00%
Used to develop and implement leveraging activities 2.00%
TOTAL 100.00%
Alternate Use of Crisis Assistance Funds, 2605(c)(1)(C)
1.3 The funds reserved for winter crisis assistance that have not been expended by March 15 will be reprogrammed to:
Heating assistance Cooling assistance
Weatherization assistance Other (specify :) Support a year-round crisis assistance program that includes heating and cooling.
Categorical Eligibility, 2605(b)(2)(A) - Assurance 2, 2605(c)(1)(A), 2605(b)(8A) - Assurance 8
1.4 Do you consider households categorically eligible if one household member receives one of the following categories of benefits in the left column below?
Yes No
If you answered "Yes" to question 1.4, you must complete the table below and answer questions 1.5 and 1.6.
Heating Cooling Crisis Weatherization
TANF Yes No Yes No Yes No Yes No
SSI Yes No Yes No Yes No Yes No
SNAP Yes No Yes No Yes No Yes No
Means-tested Veterans Programs Yes No Yes No Yes No Yes No
Program Name Heating Cooling Crisis Weatherization
Other(Specify) 1 Yes No Yes No Yes No Yes No
1.5 Do you automatically enroll households without a direct annual application? Yes No
If Yes, explain:
1.6 How do you ensure there is no difference in the treatment of categorically eligible households from those not receiving other public assistance when
determining eligibility and benefit amounts?
SNAP Nominal Payments
1.7a Do you allocate LIHEAP funds toward a nominal payment for SNAP households? Yes No
If you answered "Yes" to question 1.7a, you must provide a response to questions 1.7b, 1.7c, and 1.7d.
1.7b Amount of Nominal Assistance: $0.00
1.7c Frequency of Assistance
Once Per Year
Once every five years
Other - Describe:
1.7d How do you confirm that the household receiving a nominal payment has an energy cost or need?
Determination of Eligibility - Countable Income
1.8. In determining a household's income eligibility for LIHEAP, do you use gross income or net income?
Gross Income
Net Income
1.9. Select all the applicable forms of countable income used to determine a household's income eligibility for LIHEAP
Wages
Self - Employment Income
Contract Income
Page 5

SFY-18-L Attachment #4
Payments from mortgage or Sales Contracts
Unemployment insurance
Strike Pay
Social Security Administration (SSA ) benefits
Including MediCare deduction Excluding MediCare deduction
Supplemental Security Income (SSI )
Retirement / pension benefits
General Assistance benefits
Temporary Assistance for Needy Families (TANF) benefits
Supplemental Nutrition Assistance Program (SNAP) benefits
Women, Infants, and Children Supplemental Nutrition Program (WIC) benefits
Loans that need to be repaid
Cash gifts
Savings account balance
One-time lump-sum payments, such as rebates/credits, winnings from lotteries, refund deposits, etc.
Jury duty compensation
Rental income
Income from employment through Workforce Investment Act (WIA)
Income from work study programs
Alimony
Child support
Interest, dividends, or royalties
Commissions
Legal settlements
Insurance payments made directly to the insured
Insurance payments made specifically for the repayment of a bill, debt, or estimate
Veterans Administration (VA) benefits
Earned income of a child under the age of 18
Page 6

SFY-18-L Attachment #4
Balance of retirement, pension, or annuity accounts where funds cannot be withdrawn without a penalty.
Income tax refunds
Stipends from senior companion programs, such as VISTA
Funds received by household for the care of a foster child
Ameri-Corp Program payments for living allowances, earnings, and in-kind aid
Reimbursements (for mileage, gas, lodging, meals, etc.)
Other
Cash gifts $50 or over are counted. Earned income of a child under the age of 18 if not a full time student.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 7

SFY-18-L Attachment #4
Section 2 - HEATING ASSISTANCE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 2 - Heating Assistance
Eligibility, 2605(b)(2) - Assurance 2
2.1 Designate the income eligibility threshold used for the heating component:
Add Household size Eligibility Guideline Eligibility Threshold
1 6 State Median Income 60.00%
2 7 HHS Poverty Guidelines 150.00%
2.2 Do you have additional eligibility requirements for Yes No
HEATING ASSITANCE?
2.3 Check the appropriate boxes below and describe the policies for each.
Do you require an Assets test? Yes No
Do you have additional/differing eligibility policies for:
Renters? Yes No
Renters Living in subsidized housing? Yes No
Renters with utilities included in the rent? Yes No
Do you give priority in eligibility to:
Elderly? Yes No
Disabled? Yes No
Young children? Yes No
Households with high energy burdens? Yes No
Other? Working poor Yes No
Explanations of policies for each "yes" checked above:
Eligibility points are given to household with elderly (60+ years old), disabled, children 6 years old and under, and working poor. A household may receive one point for
each category, if eligible. Elderly participants in recertification programs may apply using an abbreviated, expedited application process, and may have their eligibility
date adjusted to the beginning of the Federal Fiscal Year for ease of administration.
Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
2.4 Describe how you prioritize the provision of heating assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc.
Eligibility points are given to household with elderly (60+ years old), disabled, children 6 years old and under, and working poor. A household may receive one
point for each category, if eligible.
2.5 Check the variables you use to determine your benefit levels. (Check all that apply):
Income
Family (household) size
Home energy cost or need:
Fuel type
Climate/region
Individual bill
Page 8

SFY-18-L Attachment #4
Dwelling type
Energy burden (% of income spent on home energy)
Energy need
Other - Describe:
Elderly, disabled, working poor, and households with children age 6 and under are given additional points for eligibility, which could increase the benefit level.
Benefit Levels, 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
2.6 Describe estimated benefit levels for FY 2016:
Minimum Benefit $75 Maximum Benefit $640
2.7 Do you provide in-kind (e.g., blankets, space heaters) and/or other forms of benefits? Yes No
If yes, describe.
Service Providers offer blankets, wood, wood pellets, and bottled propane when available.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 9

SFY-18-L Attachment #4
Section 3 - COOLING ASSISTANCE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 3 - Cooling Assistance
Eligibility, 2605(c)(1)(A), 2605 (b)(2) - Assurance 2
3.1 Designate The income eligibility threshold used for the Cooling component:
Add Household size Eligibility Guideline Eligibility Threshold
1 6 State Median Income 60.00%
2 7 HHS Poverty Guidelines 150.00%
3.2 Do you have additional eligibility requirements for Yes No
COOLING ASSITANCE?
3.3 Check the appropriate boxes below and describe the policies for each.
Do you require an Assets test? Yes No
Do you have additional/differing eligibility policies for:
Renters? Yes No
Renters Living in subsidized housing? Yes No
Renters with utilities included in the rent? Yes No
Do you give priority in eligibility to:
Elderly? Yes No
Disabled? Yes No
Young children? Yes No
Households with high energy burdens? Yes No
Other? Working poor Yes No
Explanations of policies for each "yes" checked above:
Eligibility points are given to household with elderly (60+ years old), disabled, children 6 years old and under, and working poor. A household may receive one point for
each category, if eligible. Elderly participants in recertification programs may apply using an abbreviated, expedited application process, and may have their eligibility
date adjusted to the beginning of the Federal Fiscal Year for ease of administration.
3.4 Describe how you prioritize the provision of cooling assistance to vulnerable populations, e.g., benefit amounts, early application periods, etc.
Elderly, disabled, working poor, and households with children age 6 and under are given additional points for eligibility, which could increase the benefit level.
Determination of Benefits 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
3.5 Check the variables you use to determine your benefit levels. (Check all that apply):
Income
Family (household) size
Home energy cost or need:
Fuel type
Climate/region
Individual bill
Dwelling type
Page 10

SFY-18-L Attachment #4
Energy burden (% of income spent on home energy)
Energy need
Other - Describe:
Benefit Levels, 2605(b)(5) - Assurance 5, 2605(c)(1)(B)
3.6 Describe estimated benefit levels for FY 2016:
Minimum Benefit $75 Maximum Benefit $640
3.7 Do you provide in-kind (e.g., fans, air conditioners) and/or other forms of benefits? Yes No
If yes, describe.
Service Providers provide fans when available.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 11

SFY-18-L Attachment #4
Section 4 - CRISIS ASSISTANCE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 4: CRISIS ASSISTANCE
Eligibility - 2604(c), 2605(c)(1)(A)
4.1 Designate the income eligibility threshold used for the crisis component
Add Household size Eligibility Guideline Eligibility Threshold
1 6 State Median Income 60.00%
2 7 HHS Poverty Guidelines 150.00%
4.2 Provide your LIHEAP program's definition for determining a crisis.
A crisis is defined as a delinquent or shut off notice, or if utilities are included in the rent, an eviction notice is required.
Added to the definition of a crisis is the determination of a Human Service Emergency made by the Arizona Department of Economic Security. A Human Service
Emergency includes, but is not limited to, fire or flood which results in the evacuation of homes and shelters. Upon determination of a Human Service Emergency,
households affected may be assisted with costs to temporarily shelter or house individuals in hotels, apartments, or other living situations, i.e., placing people in settings to
preserve health and safety and to move them away from the crisis situation.
4.3 What constitutes a life-threatening crisis?
A life-threatening crisis is defined as, but not limited to, individuals who are exposed to extreme out door temperatures that adversely affect their health and can potentially
directly or indirectly lead to death. A life-threatening crisis also includes individuals who must utilize life sustaining medical equipment and are either unable to pay their
utility bill or are within five days of running out of fuel/utility or being shut off. A household member's health and/or well-being would likely be endangered if energy
assistance is not provided.
Crisis Requirement, 2604(c)
4.4 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households? 48Hours
4.5 Within how many hours do you provide an intervention that will resolve the energy crisis for eligible households in life-threatening situations? 18Hours
Crisis Eligibility, 2605(c)(1)(A)
4.6 Do you have additional eligibility requirements for CRISIS ASSISTANCE? Yes No
4.7 Check the appropriate boxes below and describe the policies for each
Do you require an Assets test? Yes No
Do you give priority in eligibility to :
Elderly? Yes No
Disabled? Yes No
Young Children? Yes No
Households with high energy burdens? Yes No
Other? Yes No
In Order to receive crisis assistance:
Must the household have received a shut-off notice or have a near empty Yes No
tank?
Must the household have been shut off or have an empty tank? Yes No
Must the household have exhausted their regular heating benefit? Yes No
Must renters with heating costs included in their rent have received an
Page 12

SFY-18-L Attachment #4
eviction notice ? Yes No
Must heating/cooling be medically necessary? Yes No
Must the household have non-working heating or cooling equipment? Yes No
Other? Yes No
Do you have additional / differing eligibility policies for:
Renters? Yes No
Renters living in subsidized housing? Yes No
Renters with utilities included in the rent? Yes No
Explanations of policies for each "yes" checked above:
Although the point system is not used for LIHEAP supplemental assistance, the household must receive heating/cooling assistance either prior to or with the supplemental
payment. The point system is utilized to determine the household's LIHEAP assistance and is not recalculated for the supplemental payment.
Determination of Benefits
4.8 How do you handle crisis situations?
Separate component
Fast Track
Other - Describe:
Crisis assistance is available to applicants who have already received non-crisis assistance within a twelve (12) month period. The applicant must have a shut-off,
disconnect notice, or a notice that the utility has already been disconnected or an eviction notice if utilities are included in the rent.
4.9 If you have a separate component, how do you determine crisis assistance benefits?
Amount to resolve the crisis.
Other - Describe:
Amount to resolve crisis, up to a maximum of $500.
Crisis Requirements, 2604(c)
4.10 Do you accept applications for energy crisis assistance at sites that are geographically accessible to all households in the area to be served?
Yes No Explain.
Accommodations are made to address households in rural areas by various Service Providers offering satellite locations and partnering with local community agencies that
are geographically accessible to households. Some Service Providers travel to alternate locations to accommodate those who reside in rural areas.
4.11 Do you provide individuals who are physically disabled the means to:
Submit applications for crisis benefits without leaving their homes?
Yes No If No, explain.
Travel to the sites at which applications for crisis assistance are accepted?
Yes No If No, explain.
If you answered "No" to both options in question 4.11, please explain alternative means of intake to those who are homebound or physically disabled?
Benefit Levels, 2605(c)(1)(B)
4.12 Indicate the maximum benefit for each type of crisis assistance offered.
Winter Crisis $0.00 maximum benefit
Summer Crisis $0.00 maximum benefit
Year-round Crisis $500.00 maximum benefit
4.13 Do you provide in-kind (e.g. blankets, space heaters, fans) and/or other forms of benefits?
Yes No If yes, Describe
Page 13

SFY-18-L Attachment #4
Service Providers offer blankets, space heaters, and fans when available.
4.14 Do you provide for equipment repair or replacement using crisis funds?
Yes No
If you answered "Yes" to question 4.14, you must complete question 4.15.
4.15 Check appropriate boxes below to indicate type(s) of assistance provided.
Winter Summer Year-round Crisis
Crisis Crisis
Heating system repair
Heating system replacement
Cooling system repair
Cooling system replacement
Wood stove purchase
Pellet stove purchase
Solar panel(s)
Utility poles / gas line hook-ups
Other (Specify):
4.16 Do any of the utility vendors you work with enforce a moratorium on shut offs?
Yes No
If you responded "Yes" to question 4.16, you must respond to question 4.17.
4.17 Describe the terms of the moratorium and any special dispensation received by LIHEAP clients during or after the moratorium period.
Several of Arizona's energy vendors enforce moratoriums with varying criteria. The largest energy vendors are represented below with their specific guidelines.
In accordance with Arizona Administrative Code 14-2-211(A)(5)(c) & 14-2-201(46), Arizona Public Service (APS) uses 32 degrees Fahrenheit as the point in which they
stop disconnections for non-payment for low temperatures. In addition, APS also developed an internal business process where disconnections are suppressed for
non-payment when high heat stress indexes are present, as determined by the Phoenix Heat Alert website that relies on heat and humidity predictions from the National
Oceanic and Atmospheric Administration (NOAA).
Southwest Gas (SWG) tariff is prohibited from performing shutoffs during periods of time where weather will be especially dangerous to one's health. These weather
conditions are defined as that period of time commencing with the scheduled termination date when the local weather forecast, as predicted by the NOAA, indicates that the
temperature will not exceed 32 degrees Fahrenheit for the next day's forecast. The Corporation Commission may determine that other weather conditions are especially
dangerous to one's health as the need arises.
Salt River Project (SRP) self-initiates moratoriums in the winter and summer based on weather conditions. The duration of the self-initiated moratoriums fluctuates based
on weather conditions. The criteria for moratoriums are extreme cold temperatures or excessive heat warnings issued by the National Weather Service.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 14

SFY-18-L Attachment #4
Section 5 - WEATHERIZATION ASSISTANCE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 5: WEATHERIZATION ASSISTANCE
Eligibility, 2605(c)(1)(A), 2605(b)(2) - Assurance 2
5.1 Designate the income eligibility threshold used for the Weatherization component
Add Household Size Eligibility Guideline Eligibility Threshold
1 6 HHS Poverty Guidelines 200.00%
2 7 HHS Poverty Guidelines 200.00%
5.2 Do you enter into an interagency agreement to have another government agency administer a WEATHERIZATION component? Yes No
5.3 If yes, name the agency. Arizona Department of Housing (ADOH)
5.4 Is there a separate monitoring protocol for weatherization? Yes No
WEATHERIZATION - Types of Rules
5.5 Under what rules do you administer LIHEAP weatherization? (Check only one.)
Entirely under LIHEAP (not DOE) rules
Entirely under DOE WAP (not LIHEAP) rules
Mostly under LIHEAP rules with the following DOE WAP rule(s) where LIHEAP and WAP rules differ (Check all that apply):
Income Threshold
Weatherization of entire multi-family housing structure is permitted if at least 66% of units (50% in 2- & 4-unit buildings) are eligible units or will
become eligible within 180 days
Weatherize shelters temporarily housing primarily low income persons (excluding nursing homes, prisons, and similar institutional care facilities).
Other - Describe: Weatherization Measures are not subject to DOE Savings to Investment Ration (SIR) Standards.
Mostly under DOE WAP rules, with the following LIHEAP rule(s) where LIHEAP and WAP rules differ (Check all that apply.)
Income Threshold
Weatherization not subject to DOE WAP maximum statewide average cost per dwelling unit.
Weatherization measures are not subject to DOE Savings to Investment Ration (SIR) standards.
Other - Describe:
Eligibility, 2605(b)(5) - Assurance 5
5.6 Do you require an assets test? Yes No
5.7 Do you have additional/differing eligibility policies for :
Renters Yes No
Renters living in subsidized housing? Yes No
5.8 Do you give priority in eligibility to:
Elderly? Yes No
Disabled? Yes No
Page 15

SFY-18-L Attachment #4
Young Children? Yes No
Households with high energy burdens? Yes No
Other? Yes No
If you selected "Yes" for any of the options in questions 5.6, 5.7, or 5.8, you must provide further explanation of these policies in the text field below.
Elderly, disabled, working poor, and households with children age 6 and under are given additional points for eligibility, which could increase the benefit level.
Benefit Levels
5.9 Do you have a maximum LIHEAP weatherization benefit/expenditure per household? Yes No
5.10 If yes, what is the maximum? $7,105
Types of Assistance, 2605(c)(1), (B) & (D)
5.11 What LIHEAP weatherization measures do you provide? (Check all categories that apply.)
Weatherization needs assessments/audits Energy related roof repair
Caulking and insulation Major appliance Repairs
Storm windows Major appliance replacement
Furnace/heating system modifications/ repairs Windows/sliding glass doors
Furnace replacement Doors
Cooling system modifications/ repairs Water Heater
Water conservation measures Cooling system replacement
Compact florescent light bulbs Other - Describe:
Please see attachment 5A for full explanation.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
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SFY-18-L Attachment #4
Section 6 - Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 6: Outreach, 2605(b)(3) - Assurance 3, 2605(c)(3)(A)
6.1 Select all outreach activities that you conduct that are designed to assure that eligible households are made aware of all LIHEAP assistance available:
Place posters/flyers in local and county social service offices, offices of aging, Social Security offices, VA, etc.
Publish articles in local newspapers or broadcast media announcements.
Include inserts in energy vendor billings to inform individuals of the availability of all types of LIHEAP assistance.
Mass mailing(s) to prior-year LIHEAP recipients.
Inform low income applicants of the availability of all types of LIHEAP assistance at application intake for other low-income programs.
Execute interagency agreements with other low-income program offices to perform outreach to target groups.
Other (specify):
Service Providers periodically hold mass intake events.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 17

SFY-18-L Attachment #4
Section 7 - Coordination, 2605(b)(4) - Assurance 4
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 7: Coordination, 2605(b)(4) - Assurance 4
7.1 Describe how you will ensure that the LIHEAP program is coordinated with other programs available to low-income households (TANF, SSI, WAP, etc.).
Joint application for multiple programs
Intake referrals to/from other programs
One - stop intake centers
Other - Describe:
The Arizona Department of Economic Security will continue its policy of cooperation, coordination, and information exchange with the Arizona Department of Housing and
Federal Resources, LIHEAP Provider Agencies, Community Services Block Grant providers, the Social Security Administration, and any other Energy Programs in order to
minimize duplication of services and maximize services available to eligible clients. This cooperation is in the form of both formal and informal meetings, coordination of
contracting procedures and contractors, exchange of significant correspondence, and joint planning. Currently, the same Assistant Director administers the Community
Services, Social Services, and the Low Income Home Energy Assistance Program Block Grants. Coordination between the three Block Grants occurs on a regular basis to
ensure that the needs of the low income households are addressed. The LIHEAP Weatherization Program is administered by the Arizona Department of Housing.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 18

SFY-18-L Attachment #4
Section 8 - Agency Designation, 2605(b)(6) - Assurance 6
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 8: Agency Designation, 2605(b)(6) - Assurance 6 (Required for state grantees and the
Commonwealth of Puerto Rico)
8.1 How would you categorize the primary responsibility of your State agency?
Administration Agency
Commerce Agency
Community Services Agency
Energy / Environment Agency
Housing Agency
Welfare Agency
Other - Describe:
Alternate Outreach and Intake, 2605(b)(15) - Assurance 15
If you selected "Welfare Agency" in question 8.1, you must complete questions 8.2, 8.3, and 8.4, as applicable.
8.2 How do you provide alternate outreach and intake for HEATING ASSISTANCE?
8.3 How do you provide alternate outreach and intake for COOLING ASSISTANCE?
8.4 How do you provide alternate outreach and intake for CRISIS ASSISTANCE?
8.5 LIHEAP Component Administration. Heating Cooling Crisis Weatherization
8.5a Who determines client eligibility? Local City Government Local City Government Local City Government Local City Government
Local County Local County Local County Local County
Government Government Government Government
Community Action Community Action Community Action Community Action
Agencies Agencies Agencies Agencies
Non-profits Non-profits Non-profits Non-profits
8.5b Who processes benefit payments to gas and electric Local City Government Local City Government Local City Government
vendors? Local County Local County Local County
Government Government Government
Community Action Community Action Community Action
Agencies Agencies Agencies
Non-profits Non-profits Non-profits
8.5c who processes benefit payments to bulk fuel Local City Government Local City Government Local City Government
vendors? Local County Local County Local County
Government Government Government
Community Action Community Action Community Action
Agencies Agencies Agencies
Non-profits Non-profits Non-profits
Local City Government
Page 19

SFY-18-L Attachment #4
8.5d Who performs installation of weatherization Local County
measures? Government
Community Action
Agencies
Non-profits
If any of your LIHEAP components are not centrally-administered by a state agency, you must complete
questions 8.6, 8.7, 8.8, and, if applicable, 8.9.
8.6 What is your process for selecting local administering agencies?
In FFY 2017, there are 13 LIHEAP Providers, which consist of 12 Community Action Agencies, which were awarded as LIHEAP Providers due to the 2003
procurement code change that exempts Community Action Agencies (A.R.S §41-2081.P) and Tohono O'Odham Nation, who is a LIHEAP sub-grantee.
8.7 How many local administering agencies do you use? 13
8.8 Have you changed any local administering agencies in the last year?
Yes
No
8.9 If so, why?
Agency was in noncompliance with grantee requirements for LIHEAP -
Agency is under criminal investigation
Added agency
Agency closed
Other - describe
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 20

SFY-18-L Attachment #4
Section 9 - Energy Suppliers, 2605(b)(7) - Assurance 7
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 04/30/2014
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
Section 9: Energy Suppliers, 2605(b)(7) - Assurance 7
9.1 Do you make payments directly to home energy suppliers?
Heating Yes No
Cooling Yes No
Crisis Yes No
Are there exceptions? Yes No
If yes, Describe.
Service Providers make payments directly to Energy Suppliers on behalf of the client.
9.2 How do you notify the client of the amount of assistance paid?
Clients are notified by Service Providers via an approval letter of the amount paid on their behalf.
9.3 How do you assure that the home energy supplier will charge the eligible household, in the normal billing process, the difference between the actual cost of the
home energy and the amount of the payment?
Energy suppliers will, through their normal billing process, apply the Energy Assistance payments to the approved household's account, just as any other payment would be
applied.
9.4 How do you assure that no household receiving assistance under this title will be treated adversely because of their receipt of LIHEAP assistance?
Local Service Providers assure that households receiving LIHEAP are not treated adversely by working collaboratively with energy vendors.
9.5. Do you make payments contingent on unregulated vendors taking appropriate measures to alleviate the energy burdens of eligible households?
Yes No
If so, describe the measures unregulated vendors may take.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 21

SFY-18-L Attachment #4
Section 10 - Program, Fiscal Monitoring, and Audit, 2605(b)(10) - Assurance 10
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 10: Program, Fiscal Monitoring, and Audit, 2605(b)(10)
10.1. How do you ensure good fiscal accounting and tracking of LIHEAP funds?
Arizona Department of Economic Security assures that fiscal control and fund accounting procedures are established to assure the proper accounting of their disbursal of
federal funds paid to the state under this program, including procedures for monitoring the assistance provided under this title, and that the Arizona Auditor General's Office
includes LIHEAP in its audit of program expenditures in accordance with the Single Audit Act of 1984.
Audit Process
10.2. Is your LIHEAP program audited annually under the Single Audit Act and OMB Circular A - 133?
Yes No
10.3. Describe any audit findings rising to the level of material weakness or reportable condition cited in the A-133 audits, Grantee monitoring assessments,
inspector general reviews, or other government agency reviews of the LIHEAP agency from the most recently audited fiscal year.
No Findings
Finding Type Brief Summary Resolved? Action Taken
1
10.4. Audits of Local Administering Agencies
What types of annual audit requirements do you have in place for local adminstering agencies/district offices?
Select all that apply.
Local agencies/district offices are required to have an annual audit in compliance with Single Audit Act and OMB Circular A-133
Local agencies/district offices are required to have an annual audit (other than A-133)
Local agencies/district offices' A-133 or other independent audits are reviewed by Grantee as part of compliance process.
Grantee conducts fiscal and program monitoring of local agencies/district offices
Compliance Monitoring
10.5. Describe the Grantee's strategies for monitoring compliance with the Grantee's and Federal LIHEAP policies and procedures: Select all that apply
Grantee employees:
Internal program review
Departmental oversight
Secondary review of invoices and payments
Other program review mechanisms are in place. Describe:
Local Adminstering Agencies / District Offices:
On - site evaluation
Annual program review
Page 22

SFY-18-L Attachment #4
Monitoring through central database
Desk reviews
Client File Testing / Sampling
Other program review mechanisms are in place. Describe:
10.6 Explain, or attach a copy of your local agency monitoring schedule and protocol.
Schedule - Monitoring of Service Providers will occur at least once every three years. Any Service Provider that has a particular problem will be given technical assistance
until the problem is resolved.
Focus - Monitoring focuses on the following areas: program, fiscal, policy, and general contract requirements. Monitoring may occur through a desk review of materials or
on-site monitoring. Weatherization monitoring encompasses the aforementioned areas, plus on-site quality control inspection of weatherized homes. Monitoring visits are
also used for contractor training and technical assistance as required. Monitoring relates to Service Providers' separate evaluations of internal controls, such as control self-
assessments or internal procedures and performance. Internal monitoring processes shall be practiced by Service Providers. LIHEAP Service Providers have a responsibility
to monitor and be monitored for compliance with program requirements.
The Arizona Department of Economic Security monitors Service Providers' compliance with all requirements of federal, state, and local laws, the contractual requirements,
and directives in the policy manual. The Service Provider shall cooperate in the evaluation of contracted services. The evaluation may assess the Service Provider's progress
and/or success in achieving the goals, objectives, and deliverables set forth in their contract related to LIHEAP.
Protocol - The Arizona Department of Economic Security shall provide the Service Provider with a request for needed documents, such as case management files, and fiscal
and administrative records, at least one week prior to the scheduled monitoring date. Regarding unscheduled monitoring, the Arizona Department of Economic Security may
request needed documents while on-site without prior notice. The Arizona Department of Economic Security will communicate recommendations or findings with key
personnel and provide the opportunity for clarification, and will provide written results of the monitoring in a reasonable amount of time.
The Service Provider will ensure that key personnel are available for discussion during the scheduled monitoring and that the requested records are available and in order
beginning on the first day of the scheduled on-site monitoring visit. It is the Arizona Department of Economic Security's expectation that the monitoring will begin at the
agreed date and time for scheduled monitoring.
The on-site monitoring visit will include these activities:
The interview should include the Arizona Department of Economic Security Contract Specialist, Arizona Department of Economic Security Program Specialist and the
Service Provider's Program Manager. It may include other Arizona Department of Economic Security and Service Provider staff upon request of the Arizona Department of
Economic Security Contract Specialist, Arizona Department of Economic Security Program Specialist, or at the discretion of the Service Provider. The entrance interview
will describe the monitoring activities that will take place, review the monitoring process, and schedule interviews with other Service Provider staff, as requested by the
Arizona Department of Economic Security monitoring team.
On-site compliance monitoring will consist of a program review, with follow-up questions appropriate to the local situation. In order to complete the compliance monitoring,
the Arizona Department of Economic Security Contract Specialist and/or the Arizona Department of Economic Security Program Specialist will interview the Service
Provider Program Manager, the Fiscal Director, the position responsible for outreach activities, and any other staff whose work is integral to the program, as well as
applicants.
10.7. Describe how you select local agencies for monitoring reviews.
Site Visits:
Service Providers are monitored at least once every three years. If there are concerns related to a specific Service Provider's operations, that Provider would be a priority for
monitoring.
Desk Reviews:
Desk reviews are conducted on a monthly basis for financial and contract compliance.
10.8. How often is each local agency monitored?
Service Providers are monitored at least once every three years.
10.9. What is the combined error rate for eligibility determinations? OPTIONAL
The Arizona Department of Economic Security has not captured collective data in this area; however, resolution to eligibility determination issues is addressed at the time of
monitoring and in a formal Report of Findings.
10.10. What is the combined error rate for benefit determinations? OPTIONAL
The Arizona Department of Economic Security has not captured collective data in this area; however, resolution to eligibility determination issues is addressed at the time of
monitoring and in a formal Report of Findings.
10.11. How many local agencies are currently on corrective action plans for eligibility and/or benefit determination issues? 0
10.12. How many local agencies are currently on corrective action plans for financial accounting or administrative issues? 0
Page 23

SFY-18-L Attachment #4
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 24

SFY-18-L Attachment #4
Section 11 - Timely and Meaningful Public Participation,, 2605(b)(12) - Assurance 12, 2605(c)(2)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 11: Timely and Meaningful Public Participation, 2605(b)(12), 2605(C)(2)
11.1 How did you obtain input from the public in the development of your LIHEAP plan?
Select all that apply.
Tribal Council meeting(s)
Public Hearing(s)
Draft Plan posted to website and available for comment
Hard copy of plan is available for public view and comment
Comments from applicants are recorded
Request for comments on draft Plan is advertised
Stakeholder consultation meeting(s)
Comments are solicited during outreach activities
Other - Describe:
N/A
11.2 What changes did you make to your LIHEAP plan as a result of this participation?
The weatherization section of the State Plan was revised for clarity.
Public Hearings, 2605(a)(2) - For States and the Commonwealth of Puerto Rico Only
11.3 List the date and location(s) that you held public hearing(s) on the proposed use and distribution of your LIHEAP funds?
Date Event Description
1 07/06/2016 Tucson Public Hearing
2 07/07/2016 Flagstaff Public Hearing
3 07/05/2016 Phoenix Public Hearing
11.4. How many parties commented on your plan at the hearing(s)? 3
11.5 Summarize the comments you received at the hearing(s).
Flagstaff: Coconino County requested that the funding formula be adjusted to account for differences in rural cost of living.
Tucson: Pima County noted that a check box indicating that the State does not automatically enroll households without a direct annual application was not selected.
11.6 What changes did you make to your LIHEAP plan as a result of the comments received at the public hearing(s)?
An error was fixed after Pima County noted that the check box for section 1.5 was not selected. In addition, we are reviewing our funding formula for possible adjustment
for State Fiscal Year 2017 to account for differences in cost of living for rural areas.
Page 25

SFY-18-L Attachment #4
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 26

SFY-18-L Attachment #4
Section 12 - Fair Hearings, 2605(b)(13) - Assurance 13
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 12: Fair Hearings, 2605(b)(13) - Assurance 13
12.1 How many fair hearings did the grantee have in the prior Federal fiscal year? 0
12.2 How many of those fair hearings resulted in the initial decision being reversed? 0
12.3 Describe any policy and/or procedural changes made in the last Federal fiscal year as a result of fair hearings?
No policy and/or procedural changes were made in the last federal fiscal year as a result of fair hearings.
12.4 Describe your fair hearing procedures for households whose applications are denied.
A Fair Hearing procedure is in place within the Department of Economic Security (DES), Division of Aging and Adult Services (DAAS), Community Action Programs and
Services Administration, and the Community Action Agencies (CAAs). Clients will be notified at time of application of their right to appeal.
Step One: An opportunity to file a request for a fair hearing regarding any adverse action shall be granted by the CAA to any applicant/recipient who requests a hearing
because his or her benefit assistance is denied, delayed, discontinued, suspended, or terminated. The applicant/recipient must, within ten working days, provide in writing a
statement of the grounds for the hearing. The request must be submitted to the CAA within ten working days after the mailing date on the decision letter. The CAA
receiving the grievance will make all efforts to resolve the issues within ten working days of the request.
Step Two: In the event the applicant/recipient wishes to appeal the decision of the CAA, the applicant/recipient may, within ten working days of receiving the CAA decision
letter, appeal in writing to the Arizona Department of Economic Security Assistant Director. The Assistant Director will assign the appropriate personnel to conduct the
hearing. A decision will be provided within ten working days of the appeal letter.
Step Three: In the event the applicant/recipient wishes to appeal the decision of the Arizona Department of Economic Security Assistant Director, the applicant/recipient
may, within ten working days of receiving the Arizona Department of Economic Security Assistant Director's decision letter, request in writing a fair hearing from the
Arizona Court of Appeals. The Arizona Court of Appeals will be responsible for conducting the hearing and providing a decision within 60 days of the request.
Step Four: In the event the applicant/recipient wishes to appeal the decision of the Arizona Court of Appeals, the applicant/recipient may, within ten working days of
receiving the Arizona Court of Appeals decision letter, request in writing a fair hearing from the Department of Health and Human Services, Office of Community Services
in Washington D.C. The Department of Health and Human Services, Office of Community Services in Washington D.C. will be responsible for providing a decision within
60 days of the request.
12.5 When and how are applicants informed of these rights?
Applicants are informed of the right to a fair hearing through notices posted in Service Providers' waiting areas and in writing and verbally during their initial intake
appointment. Applicants are informed through a written notice either included in the packet provided prior to the intake appointment or during the intake appointment.
12.6 Describe your fair hearing procedures for households whose applications are not acted on in a timely manner.
A Fair Hearing procedure is in place within the Department of Economic Security (DES), Division of Aging and Adult Services (DAAS), Community Action Programs and
Services Administration and the Community Action Agencies (CAAs). Clients will be notified at time of application of their right to appeal.
Step One: An opportunity to file a request for a fair hearing regarding any adverse action shall be granted by the CAA to any applicant/recipient who requests a hearing
because his or her benefit assistance is denied, delayed, discontinued, suspended, or terminated. The applicant/recipient must, within ten working days, provide in writing a
statement of the grounds for the hearing. The request must be submitted to the CAA within ten working days after the mailing date on the decision letter. The CAA
receiving the grievance will make all efforts to resolve the issues within ten working days of the request.
Step Two: In the event the applicant/recipient wishes to appeal the decision of the CAA, the applicant/recipient may, within ten working days of receiving the CAA decision
letter, appeal in writing to the Arizona Department of Economic Security Assistant Director. The Assistant Director will assign the appropriate personnel to conduct the
hearing. A decision will be provided within ten working days of the appeal letter.
Step Three: In the event the applicant/recipient wishes to appeal the decision of the Arizona Department of Economic Security Assistant Director, the applicant/recipient
may, within ten working days of receiving the Arizona Department of Economic Security Assistant Director's decision letter, request in writing a fair hearing from the
Page 27

SFY-18-L Attachment #4
Arizona Court of Appeals. The Arizona Court of Appeals will be responsible for conducting the hearing and providing a decision within 60 days of the request.
Step Four: In the event the applicant/recipient wishes to appeal the decision of the Arizona Court of Appeals, the applicant/recipient may, within ten working days of
receiving the Arizona Court of Appeals' decision letter, request in writing a fair hearing from the Department of Health and Human Services, Office of Community Services
in Washington D.C. The Department of Health and Human Services, Office of Community Services in Washington D.C. will be responsible for providing a decision within
60 days of the request.
12.7 When and how are applicants informed of these rights?
Applicants are informed of the right to a fair hearing through notices posted in Service Providers' waiting areas and in writing and verbally during their initial intake
appointment. Applicants are informed through a written notice either included in the packet provided prior to the intake appointment or during the intake appointment.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 28

SFY-18-L Attachment #4
Section 13 - Reduction of home energy needs, 2605(b)(16) - Assurance 16
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 13: Reduction of home energy needs, 2605(b)(16) - Assurance 16
13.1 Describe how you use LIHEAP funds to provide services that encourage and enable households to reduce their home energy needs and thereby the need for
energy assistance?
Service Providers offer energy reduction education through various methods such as brochures, teaching applicants during the application process, in-house tutorial videos
presented in waiting areas, and/or classes.
13.2 How do you ensure that you don't use more than 5% of your LIHEAP funds for these activities?
To ensure that no more than 5% of LIHEAP funding is used for Assurance 16 purposes, the Arizona Department of Economic Security utilizes fiscal and program controls,
including fund accounting procedures, to assure that Service Providers abide by the federal guidelines.
13.3 Describe the impact of such activities on the number of households served in the previous Federal fiscal year.
The Arizona Department of Economic Security has not collected this LIHEAP data for FFY 2016; however, DES is working with APPRISE to collect this data for future
reports.
13.4 Describe the level of direct benefits provided to those households in the previous Federal fiscal year.
FFY 2016 data is not finalized; however, the data is forthcoming in the Performance Data Form.
13.5 How many households applied for these services? Applicants do not apply for these services; they are offered the education during their initial intake appointment.
FFY 2016 data is not yet available.
13.6 How many households received these services? FFY 2016 data is not yet available.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 29

SFY-18-L Attachment #4
Section 14 - Leveraging Incentive Program, 2607A
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 14:Leveraging Incentive Program, 2607(A)
14.1 Do you plan to submit an application for the leveraging incentive program?
Yes No
14.2 Describe instructions to any third parties and/or local agencies for submitting LIHEAP leveraging resource information and retaining records.
When funding is made available, a request for submittal is emailed to Service Providers along with all pertinent attachments (blank leveraging report and previous year
report/reports submitted, if applicable) with a deadline to submit all leveraging resource reports by October 15th.
14.3 For each type of resource and/or benefit to be leveraged in the upcoming year that will meet the requirements of45 C.F.R. Â§ 96.87(d)(2)(iii),describe the
following:
Resource What is the type of What is the source(s) of the How will the resource be integrated and coordinated with LIHEAP?
resource or benefit ? resource ?
Arizona Public Service Provides a discount to
1 (APS) households based on electricity D
usage for each month.
Funds are intended for the
issuance of Emergency
Assistance to clients. The
City of Phoenix General General Purpose Fund assists
2 Purpose Fund eligible clients in meeting N/A
certain immediate financial
needs for which no alternative
community resources are
available.
City of Tucson Low Funds are used to provide a
3 Income Assistance discount to low income A
Program households with water bills.
Funds are used to provide low
Coconino County income Coconino County
4 General Funds residents with financial A, C and E
assistance with utility bills in
conjunction with LIHEAP.
Funds for Home Energy
5 Neighbors Helping Assistance available statewide. E
Neighbors Funds are received through a
voluntary State Tax check off.
Funds are used to provide low
Pima County General income Pima County residents
6 Fund Utility Assistance with financial assistance with N/A
utility bills in conjunction with
LIHEAP.
Fuel fund providing benefits
within the LIHEAP program
statewide. Project SHARE
provides benefits to households
who have already been assisted
7 Salvation Army Project by LIHEAP but are still in a A
SHARE crisis situation or applicant has
gone to a Community Action
Agency (CAA) first and the
CAA has no funding available,
only benefits to LIHEAP eligible
households are counted.
LIRA provides a 30 percent
Page 30

SFY-18-L Attachment #4
reduction on the per thermal rate
Southwest Gas (SWG) applied to the first 150 thermals
Corporation Low of natural gas used each month
8 Income Rate Assistance from November 1 through April N/A
Program (LIRA) 30 and on the service
establishment and/or
reestablishment charge year
round.
SWG provides funding to
Community Action Agencies
(CAA) to meet the energy
affordability needs of low
income customers through a
9 SWG Low Income coordinated partnership. CAAs A
Energy Conservation serving SWG territory will
coordinate and deliver the
program elements in conjunction
with their existing activities for
the Weatherization and LIHEAP
programs.
SWG donated hot water heaters
to be installed in low income
SWG Donated Water households. Households are
10 Heaters assessed on energy consumption A
and condition of unit,
LIHEAP/WAP criteria is used to
determine eligibility.
Provides a discount to low
income households at 150
TEP LIFELINE percent based on electricity
11 Discount Program usage for each month. The D
CAAs take applications and
assist clients through the
application process.
TEP funds to provide
weatherization services,
12 TEP Weatherization specifically designed to lower D
energy burden for qualified
homeowners.
Unisource Energy
Services Customers Home energy discounts that
13 Assistance Residential reduce low income householdsÂ D
Energy Support utility bills.
Program-Gas
UniSource Energy Services
funds cover weatherization
Unisource Energy strategies specifically designed
14 Services Weatherization to lower energy burden for G
Program qualified homeowners, and are
leveraged/combined with other
funding sources for
comprehensive home repairs.
Unisource Energy Services-Gas
and Electric Divisions collect
15 Warm Spirit donations from customers and D
businesses to provide utility
assistance to low income
households.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 31

SFY-18-L Attachment #4
Section 15 - Training
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 15: Training
15.1 Describe the training you provide for each of the following groups:
a. Grantee Staff:
Formal training on grantee policies and procedures
How often?
Annually
Biannually
As needed
Other - Describe:
Employees are provided with policy manual
Other-Describe:
Arizona Department of Economic Security LIHEAP Staff receives formal training from the Office of Community Services and National Energy Assistance Directors
Association.
b. Local Agencies:
Formal training conference
How often?
Annually
Biannually
As needed
Other - Describe: Service Providers also attend various National, OCS, and other LIHEAP training via conferences at their discretion.
On-site training
How often?
Annually
Biannually
As needed
Other - Describe:
Employees are provided with policy manual
Other - Describe
c. Vendors
Formal training conference
How often?
Annually
Biannually
As needed
Page 32

SFY-18-L Attachment #4
Other - Describe:
Policies communicated through vendor agreements
Policies are outlined in a vendor manual
Other - Describe:
Vendors are provided with current LIHEAP Policy Manuals. Questions and concerns are communicated verbally and via email.
15.2 Does your training program address fraud reporting and prevention?
Yes
No
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
Page 33

SFY-18-L Attachment #4
Section 16 - Performance Goals and Measures, 2605(b)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 16: Performance Goals and Measures, 2605(b) - Required for States Only
16.1 Describe your progress toward meeting the data collection and reporting requirements of the four required LIHEAP performance measures. Include
timeframes and plans for meeting these requirements and what you believe will be accomplished in the coming federal fiscal year.
The State of Arizona (AZ) is working with APPRISE Consultants to accomplish LIHEAP Performance Measures Data Collection for FFY 2016. Abbreviated Data
Templates for FFY 2015 were submitted to APPRISE in order to assist Arizona completion of the 2015 Household Report. Performance Measures monthly templates have
been submitted by CAAs to AZ since October 2015. Teleconference calls, as well as face-to-face meetings, were conducted on a monthly basis with the CAA network
beginning in April 2015 to provide unduplicated data for FFY 2016 reporting. Memorandums of Understanding and Data Sharing Agreements have been signed by the top
five energy vendors in the State. AZ anticipates full implementation of LIHEAP Data Collection in October 2016. A statewide database system is still being considered.
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
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SFY-18-L Attachment #4
Section 17 - Program Integrity, 2605(b)(10)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES August 1987, revised OMB 05/92,02/95,03/96,12/98,11/01 Clearance No.: 0970-0075
ADMINISTRATION FOR CHILDREN AND FAMILIES
Expiration Date: 06/30/2017
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
MODEL PLAN
SF - 424 - MANDATORY
Section 17: Program Integrity, 2605(b)(10)
17.1 Fraud Reporting Mechanisms
a. Describe all mechanisms available to the public for reporting cases of suspected waste, fraud, and abuse. Select all that apply.
Online Fraud Reporting
Dedicated Fraud Reporting Hotline
Report directly to local agency/district office or Grantee office
Report to State Inspector General or Attorney General
Forms and procedures in place for local agencies/district offices and vendors to report fraud, waste, and abuse
Other - Describe:
A dedicated fraud reporting hotline is in place for statewide fraud abuse and it not specific to LIHEAP.
b. Describe strategies in place for advertising the above-referenced resources. Select all that apply
Printed outreach materials
Addressed on LIHEAP application
Website
Other - Describe:
17.2. Identification Documentation Requirements
a. Indicate which of the following forms of identification are required or requested to be collected from LIHEAP applicants or their household members.
Collected from Whom?
Type of Identification Collected
Applicant Only All Adults in Household All Household Members
Required Required Required
Social Security Card is photocopied
and retained
Requested Requested Requested
Required Required Required
Social Security Number (Without
actual Card)
Requested Requested Requested
Required Required Required
Government-issued identification
card
(i.e.: driver's license, state ID, Tribal
ID, passport, etc.) Requested Requested Requested
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SFY-18-L Attachment #4
Applicant Only Applicant Only All Adults in All Adults in All Household All Household
Other Required Requested Household Household Members Members
Required Requested Required Requested
Other documents that State uses for
identification verification are; wage
stubs, work and school identification
cards, Arizona State Driver's License
and identification cards, birth
certificates, birth records, Certificates
of Indian Blood (CIBs), tribal
1 identification cards, 1 housing authority
(section 8) documents, social security
cards and documents, family census
cards, health benefit identification
cards, social service program
documents or cards, passports, legal
permanent residence documents, tax
returns and voter registration cards.
b. Describe any exceptions to the above policies.
Some Service Providers verify SSNs with the State eligibility/management system (e.g. SNAP, TANF).
17.3 Identification Verification
Describe what methods are used to verify the authenticity of identification documents provided by clients or household members. Select all that apply
Verify SSNs with Social Security Administration
Match SSNs with death records from Social Security Administration or state agency
Match SSNs with state eligibility/case management system (e.g., SNAP, TANF)
Match with state Department of Labor system
Match with state and/or federal corrections system
Match with state child support system
Verification using private software (e.g., The Work Number)
In-person certification by staff (for tribal grantees only)
Match SSN/Tribal ID number with tribal database or enrollment records (for tribal grantees only)
Other - Describe:
Some Service Providers verify SSNs with the State eligibility/management system (e.g. SNAP, TANF).
17.4. Citizenship/Legal Residency Verification
What are your procedures for ensuring that household members are U.S. citizens or aliens who are qualified to receive LIHEAP benefits? Select all that apply.
Clients sign an attestation of citizenship or legal residency
Client's submission of Social Security cards is accepted as proof of legal residency
Noncitizens must provide documentation of immigration status
Citizens must provide a copy of their birth certificate, naturalization papers, or passport
Noncitizens are verified through the SAVE system
Tribal members are verified through Tribal enrollment records/Tribal ID card
Other - Describe: Some Service Providers verify Citizenship/Legal Residency Status with the State eligibility/management system (e.g. SNAP, TANF).
17.5. Income Verification
What methods does your agency utilize to verify household income? Select all that apply.
Require documentation of income for all adult household members
Pay stubs
Social Security award letters
Bank statements
Tax statements
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SFY-18-L Attachment #4
Zero-income statements
Unemployment Insurance letters
Other - Describe:
Clients must provide verification for unearned income. Agencies require documentation of income for all adult household members and persons age 16 or above who are not
full-time students. Agencies may, at their discretion, accept a participant statement as verification for income when the client has attempted but is unable to provide the
verification, no other source of verification is available, and agency staff have attempted to assist in obtaining the verification on behalf of the client. When a partial month of
check stubs is available, the documents available will be used to calculate the income received during the period lacking documentation.
Computer data matches:
Income information matched against state computer system (e.g., SNAP, TANF)
Proof of unemployment benefits verified with state Department of Labor
Social Security income verified with SSA
Utilize state directory of new hires
Other - Describe:
17.6. Protection of Privacy and Confidentiality
Describe the financial and operating controls in place to protect client information against improper use or disclosure. Select all that apply.
Policy in place prohibiting release of information without written consent
Grantee LIHEAP database includes privacy/confidentiality safeguards
Employee training on confidentiality for:
Grantee employees
Local agencies/district offices
Employees must sign confidentiality agreement
Grantee employees
Local agencies/district offices
Physical files are stored in a secure location
Other - Describe:
17.7. Verifying the Authenticity
What policies are in place for verifying vendor authenticity? Select all that apply.
All vendors must register with the State/Tribe.
All vendors must supply a valid SSN or TIN/W-9 form
Vendors are verified through energy bills provided by the household
Grantee and/or local agencies/district offices perform physical monitoring of vendors
Other - Describe and note any exceptions to policies above:
17.8. Benefits Policy - Gas and Electric Utilities
What policies are in place to protect against fraud when making benefit payments to gas and electric utilities on behalf of clients? Select all that apply.
Applicants required to submit proof of physical residency
Applicants must submit current utility bill
Data exchange with utilities that verifies:
Account ownership
Consumption
Balances
Payment history
Account is properly credited with benefit
Other - Describe:
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SFY-18-L Attachment #4
Centralized computer system/database tracks payments to all utilities
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SFY-18-L Attachment #4
Centralized computer system automatically generates benefit level
Separation of duties between intake and payment approval
Payments coordinated among other energy assistance programs to avoid duplication of payments
Payments to utilities and invoices from utilities are reviewed for accuracy
Computer databases are periodically reviewed to verify accuracy and timeliness of payments made to utilities
Direct payment to households are made in limited cases only
Procedures are in place to require prompt refunds from utilities in cases of account closure
Vendor agreements specify requirements selected above, and provide enforcement mechanism
Other - Describe:
Some Service Providers utilize computer databases to periodically review and verify accuracy and timeliness of payments made to utilities.
17.9. Benefits Policy - Bulk Fuel Vendors
What procedures are in place for averting fraud and improper payments when dealing with bulk fuel suppliers of heating oil, propane, wood, and other bulk fuel
vendors? Select all that apply.
Vendors are checked against an approved vendors list
Centralized computer system/database is used to track payments to all vendors
Clients are relied on for reports of non-delivery or partial delivery
Two-party checks are issued naming client and vendor
Direct payment to households are made in limited cases only
Vendors are only paid once they provide a delivery receipt signed by the client
Conduct monitoring of bulk fuel vendors
Bulk fuel vendors are required to submit reports to the Grantee
Vendor agreements specify requirements selected above, and provide enforcement mechanism
Other - Describe:
Service Providers directly pay vendors and keep accounting records which are monitored by the Arizona Department of Economic Security to avert fraud and improper
payments.
17.10. Investigations and Prosecutions
Describe the Grantee's procedures for investigating and prosecuting reports of fraud, and any sanctions placed on clients/staff/vendors found to have committed
fraud. Select all that apply.
Refer to state Inspector General
Refer to local prosecutor or state Attorney General
Refer to US DHHS Inspector General (including referral to OIG hotline)
Local agencies/district offices or Grantee conduct investigation of fraud complaints from public
Grantee attempts collection of improper payments. If so, describe the recoupment process
Clients found to have committed fraud are banned from LIHEAP assistance. For how long is a household banned?
Contracts with local agencies require that employees found to have committed fraud are reprimanded and/or terminated
Vendors found to have committed fraud may no longer participate in LIHEAP
Other - Describe:
If any of the above questions require further explanation or clarification that could not be made in the fields provided,
attach a document with said explanation here.
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SFY-18-L Attachment #4
Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility Matters
Section 18: Certification Regarding Debarment, Suspension, and Other Responsibility
Matters
Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary
Covered Transactions
Instructions for Certification
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not necessarily
result in denial of participation in this covered transaction. The prospective participant
shall submit an explanation of why it cannot provide the certification set out below. The
certification or explanation will be considered in connection with the department or
agency's determination whether to enter into this transaction. However, failure of the
prospective primary participant to furnish a certification or an explanation shall disqualify
such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which reliance
was placed when the department or agency determined to enter into this transaction. If it is
later determined that the prospective primary participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.BrBbr.
4. The prospective primary participant shall provide immediate written notice to the
department or agency to which this proposal is submitted if at any time the prospective
primary participant learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, lower tier covered
transaction, participant, person, primary covered transaction, principal, proposal, and
voluntarily excluded, as used in this clause, have the meanings set out in the Definitions
and Coverage sections of the rules implementing Executive Order 12549. You may contact
the department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. The prospective primary participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter into any lower
tier covered transaction with a person who is proposed for debarment under 48 CFR part 9,
subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the department or agency
entering into this transaction.
7. The prospective primary participant further agrees by submitting this proposal that it
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SFY-18-L Attachment #4
will include the clause titled ``Certification Regarding Debarment, Suspension, Ineligibility
and Voluntary Exclusion-Lower Tier Covered Transaction,'' provided by the department or
agency entering into this covered transaction, without modification, in all lower tier
covered transactions and in all solicitations for lower tier covered transactions.
8. A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not proposed for debarment under
48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from
the covered transaction, unless it knows that the certification is erroneous. A participant
may decide the method and frequency by which it determines the eligibility of its
principals. Each participant may, but is not required to, check the List of Parties Excluded
from Federal Procurement and Nonprocurement Programs.
9. Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this clause.
The knowledge and information of a participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of business dealings.
10. Except for transactions authorized under paragraph 6 of these instructions, if a
participant in a covered transaction knowingly enters into a lower tier covered transaction
with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4,
suspended, debarred, ineligible, or voluntarily excluded from participation in this
transaction, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.
Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary
Covered Transactions
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of or had a
civil judgment rendered against them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State or
local) transaction or contract under a public transaction; violation of Federal or State
antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State or local) with commission of any of the offenses
enumerated in paragraph (1)(b) of this certification; and
(d) Have not within a three-year period preceding this application/proposal had one or
more public transactions (Federal, State or local) terminated for cause or default.
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SFY-18-L Attachment #4
(2) Where the prospective primary participant is unable to certify to any of the statements
in this certification, such prospective participant shall attach an explanation to this
proposal.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier
Covered Transactions
Instructions for Certification
1. By signing and submitting this proposal, the prospective lower tier participant is providing the
certification set out below.
2. The certification in this clause is a material representation of fact upon which reliance was
placed when this transaction was entered into. If it is later determined that the prospective lower
tier participant knowingly rendered an erroneous certification, in addition to other remedies
available to the Federal Government the department or agency with which this transaction
originated may pursue available remedies, including suspension and/or debarment.
3. The prospective lower tier participant shall provide immediate written notice to the person to
which this proposal is submitted if at any time the prospective lower tier participant learns that its
certification was erroneous when submitted or had become erroneous by reason of changed
circumstances.
4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction,
participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meaning set out in the Definitions and Coverage sections of rules
implementing Executive Order 12549. You may contact the person to which this proposal is
submitted for assistance in obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, [[Page
33043]] should the proposed covered transaction be entered into, it shall not knowingly
enter into any lower tier covered transaction with a person who is proposed for debarment
under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily
excluded from participation in this covered transaction, unless authorized by the
department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this proposal that it
will include this clause titled ``Certification Regarding Debarment, Suspension, Ineligibility
and Voluntary Exclusion-Lower Tier Covered Transaction,'' without modification, in all
lower tier covered transactions and in all solicitations for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not proposed for debarment under
48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from
covered transactions, unless it knows that the certification is erroneous. A participant may
decide the method and frequency by which it determines the eligibility of its principals.
Each participant may, but is not required to, check the List of Parties Excluded from
Federal Procurement and Nonprocurement Programs.
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SFY-18-L Attachment #4
8. Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this clause.
The knowledge and information of a participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of business dealings.
9. Except for transactions authorized under paragraph 5 of these instructions, if a
participant in a covered transaction knowingly enters into a lower tier covered transaction
with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4,
suspended, debarred, ineligible, or voluntarily excluded from participation in this
transaction, in addition to other remedies available to the Federal Government, the
department or agency with which this transaction originated may pursue available
remedies, including suspension and/or debarment.
Certification Regarding Debarment, Suspension, Ineligibility an Voluntary
Exclusion--Lower Tier Covered Transactions
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it
nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from participation in this transaction by any Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in this
certification, such prospective participant shall attach an explanation to this proposal.
By checking this box, the prospective primary participant is providing the certification
set out above.
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SFY-18-L Attachment #4
Section 19: Certification Regarding Drug-Free Workplace Requirements
Section 19: Certification Regarding Drug-Free Workplace Requirements
This certification is required by the regulations implementing the Drug-Free Workplace Act
of 1988: 45 CFR Part 76, Subpart, F. Sections 76.630(c) and (d)(2) and 76.645(a)(1) and (b)
provide that a Federal agency may designate a central receipt point for STATE-WIDE AND
STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For
the Department of Health and Human Services, the central pint is: Division of Grants
Management and Oversight, Office of Management and Acquisition, Department of Health
and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201.
Certification Regarding Drug-Free Workplace Requirements (Instructions for Certification)
1. By signing and/or submitting this application or grant agreement, the grantee is
providing the certification set out below.
2. The certification set out below is a material representation of fact upon which reliance is
placed when the agency awards the grant. If it is later determined that the grantee
knowingly rendered a false certification, or otherwise violates the requirements of the
Drug-Free Workplace Act, the agency, in addition to any other remedies available to the
Federal Government, may take action authorized under the Drug-Free Workplace Act.
3. For grantees other than individuals, Alternate I applies.
4. For grantees who are individuals, Alternate II applies.
5. Workplaces under grants, for grantees other than individuals, need not be identified on
the certification. If known, they may be identified in the grant application. If the grantee
does not identify the workplaces at the time of application, or upon award, if there is no
application, the grantee must keep the identity of the workplace(s) on file in its office and
make the information available for Federal inspection. Failure to identify all known
workplaces constitutes a violation of the grantee's drug-free workplace requirements.
6. Workplace identifications must include the actual address of buildings (or parts of
buildings) or other sites where work under the grant takes place. Categorical descriptions
may be used (e.g., all vehicles of a mass transit authority or State highway department
while in operation, State employees in each local unemployment office, performers in
concert halls or radio studios).
7. If the workplace identified to the agency changes during the performance of the grant,
the grantee shall inform the agency of the change(s), if it previously identified the
workplaces in question (see paragraph five).
8. Definitions of terms in the Nonprocurement Suspension and Debarment common rule
and Drug-Free Workplace common rule apply to this certification. Grantees' attention is
called, in particular, to the following definitions from these rules:
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SFY-18-L Attachment #4
Controlled substance means a controlled substance in Schedules I through V of the
Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR
1308.11 through 1308.15);
Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of
sentence, or both, by any judicial body charged with the responsibility to determine
violations of the Federal or State criminal drug statutes;
Criminal drug statute means a Federal or non-Federal criminal statute involving the
manufacture, distribution, dispensing, use, or possession of any controlled substance;
Employee means the employee of a grantee directly engaged in the performance of work
under a grant, including: (i) All direct charge employees; (ii) All indirect charge employees
unless their impact or involvement is insignificant to the performance of the grant; and, (iii)
Temporary personnel and consultants who are directly engaged in the performance of
work under the grant and who are on the grantee's payroll. This definition does not include
workers not on the payroll of the grantee (e.g., volunteers, even if used to meet a matching
requirement; consultants or independent contractors not on the grantee's payroll; or
employees of subrecipients or subcontractors in covered workplaces).
Certification Regarding Drug-Free Workplace Requirements
Alternate I. (Grantees Other Than Individuals)
The grantee certifies that it will or will continue to provide a drug-free workplace by:,
(a) Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the grantee's workplace
and specifying the actions that will be taken against employees for violation of such prohibition;
(b) Establishing an ongoing drug-free awareness program to inform employees about --
(1)The dangers of drug abuse in the workplace;
(2) The grantee's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
c) Making it a requirement that each employee to be engaged in the performance of the
grant be given a copy of the statement required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that, as a condition
of employment under the grant, the employee will --
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a violation of a criminal drug
statute occurring in the workplace no later than five calendar days after such conviction;
(e) Notifying the agency in writing, within ten calendar days after receiving notice under
paragraph (d)(2) from an employee or otherwise receiving actual notice of such conviction.
Employers of convicted employees must provide notice, including position title, to every
grant officer or other designee on whose grant activity the convicted employee was
working, unless the Federal agency has designated a central point for the receipt of such
notices. Notice shall include the identification number(s) of each affected grant;
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SFY-18-L Attachment #4
(f)Taking one of the following actions, within 30 calendar days of receiving notice under
paragraph (d)(2), with respect to any employee who is so convicted -(1) Taking appropriate
personnel action against such an employee, up to and including termination, consistent
with the requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health, law
enforcement, or other appropriate agency;
(g) Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs (a), (b), (c), (d), (e) and (f).
(B) The grantee may insert in the space provided below the site(s) for the performance of
work done in connection with the specific grant:
Place of Performance (Street address, city, county, state, zip code)
1789 W Jefferson
* Address Line 1
Address Line 2
Address Line 3
Phoenix Arizona 85007
* City * State * Zip Code
Check if there are workplaces on file that are not identified here.
Alternate II. (Grantees Who Are Individuals)
(a) The grantee certifies that, as a condition of the grant, he or she will not engage in the
unlawful manufacture, distribution, dispensing, possession, or use of a controlled
substance in conducting any activity with the grant;
(b) If convicted of a criminal drug offense resulting from a violation occurring during the
conduct of any grant activity, he or she will report the conviction, in writing, within 10
calendar days of the conviction, to every grant officer or other designee, unless the
Federal agency designates a central point for the receipt of such notices. When notice is
made to such a central point, it shall include the identification number(s) of each affected
grant.
[55 FR 21690, 21702, May 25, 1990]
By checking this box, the prospective primary participant is providing the certification
set out above.
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SFY-18-L Attachment #4
Section 20: Certification Regarding Lobbying
Section 20: Certification Regarding Lobbying
The submitter of this application certifies, to the best of his or her knowledge and belief,
that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or
employee of an agency, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with the awarding of any Federal
contract, the making of any Federal grant, the making of any Federal loan, the entering into
of any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this Federal contract, grant, loan, or cooperative agreement,
the undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to
Report Lobbying,'' in accordance with its instructions
(3) The undersigned shall require that the language of this certification be included in the
award documents for all subawards at all tiers (including subcontracts, subgrants, and
contracts under grants, loans, and cooperative agreements) and that all subrecipients
shall certify and disclose accordingly. This certification is a material representation of fact
upon which reliance was placed when this transaction was made or entered into.
Submission of this certification is a prerequisite for making or entering into this
transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with this
commitment providing for the United States to insure or guarantee a loan, the undersigned
shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,'' in
accordance with its instructions. Submission of this statement is a prerequisite for making
or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person
who fails to file the required statement shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
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SFY-18-L Attachment #4
By checking this box, the prospective primary participant is providing the certification
set out above.
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SFY-18-L Attachment #4
Assurances
Assurances
(1) use the funds available under this title to--
(A) conduct outreach activities and provide assistance to low income households in
meeting their home energy costs, particularly those with the lowest incomes that pay a
high proportion of household income for home energy, consistent with paragraph (5);
(B) intervene in energy crisis situations;
(C) provide low-cost residential weatherization and other cost-effective energy-related
home repair;and
(D)plan, develop, and administer the State's program under this title including leveraging
programs, and the State agrees not to use such funds for any purposes other than those
specified in this title;
(2) make payments under this title only with respect to--
(A) households in which one or more individuals are receiving--
(i) assistance under the State program funded under part A of title IV of the Social
Security Act;
(ii) supplemental security income payments under title XVI of the Social Security Act;
(iii) food stamps under the Food Stamp Act of 1977; or
(iv) payments under section 415, 521, 541, or 542 of title 38, United States Code, or
under section 306 of the Veterans' and Survivors' Pension Improvement Act of 1978;
or
(B) households with incomes which do not exceed the greater of -
(i) an amount equal to 150 percent of the poverty level for such State; or
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SFY-18-L Attachment #4
(ii) an amount equal to 60 percent of the State median income;
(except that a State may not exclude a household from eligibility in a fiscal year solely
on the basis of household income if such income is less than 110 percent of the
poverty level for such State, but the State may give priority to those households with
the highest home energy costs or needs in relation to household income.
(3) conduct outreach activities designed to assure that eligible households,
especially households with elderly individuals or disabled individuals, or both, and
households with high home energy burdens, are made aware of the assistance
available under this title, and any similar energy-related assistance available under
subtitle B of title VI (relating to community services block grant program) or under
any other provision of law which carries out programs which were administered
under the Economic Opportunity Act of 1964 before the date of the enactment of this
Act;(4) coordinate its activities under this title with similar and related programs
administered by the Federal Government and such State, particularly low-income
energy-related programs under subtitle B of title VI (relating to community services
block grant program), under the supplemental security income program, under part A
of title IV of the Social Security Act, under title XX of the Social Security Act, under
the low-income weatherization assistance program under title IV of the Energy
Conservation and Production Act, or under any other provision of law which carries
out programs which were administered under the Economic Opportunity Act of 1964
before the date of the enactment of this Act;(5) provide, in a timely manner, that the
highest level of assistance will be furnished to those households which have the
lowest incomes and the highest energy costs or needs in relation to income, taking
into account family size, except that the State may not differentiate in implementing
this section between the households described in clauses 2(A) and 2(B) of this
subsection;
(6) to the extent it is necessary to designate local administrative agencies in order to carry
out the purposes of this title, to give special consideration, in the designation of such
agencies, to any local public or private nonprofit agency which was receiving Federal
funds under any low-income energy assistance program or weatherization program under
the Economic Opportunity Act of 1964 or any other provision of law on the day before the
date of the enactment of this Act, except that -
(A) the State shall, before giving such special consideration, determine that the agency
involved meets program and fiscal requirements established by the State; and
(B) if there is no such agency because of any change in the assistance furnished to
programs for economically disadvantaged persons, then the State shall give special
consideration in the designation of local administrative agencies to any successor agency
which is operated in substantially the same manner as the predecessor agency which did
receive funds for the fiscal year preceding the fiscal year for which the determination is
made;
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SFY-18-L Attachment #4
(7) if the State chooses to pay home energy suppliers directly, establish procedures to --
(A) notify each participating household of the amount of assistance paid on its behalf;
(B) assure that the home energy supplier will charge the eligible household, in the normal
billing process, the difference between the actual cost of the home energy and the amount
of the payment made by the State under this title;
(C) assure that the home energy supplier will provide assurances that any agreement
entered into with a home energy supplier under this paragraph will contain provisions to
assure that no household receiving assistance under this title will be treated adversely
because of such assistance under applicable provisions of State law or public regulatory
requirements; and
(D) ensure that the provision of vendor payments remains at the option of the State in
consultation with local grantees and may be contingent on unregulated vendors taking
appropriate measures to alleviate the energy burdens of eligible households, including
providing for agreements between suppliers and individuals eligible for benefits under this
Act that seek to reduce home energy costs, minimize the risks of home energy crisis, and
encourage regular payments by individuals receiving financial assistance for home energy
costs;
(8) provide assurances that,
(A) the State will not exclude households described in clause (2)(B) of this subsection from
receiving home energy assistance benefits under clause (2), and
(B) the State will treat owners and renters equitably under the program assisted under this
title;
(9) provide that--
(A) the State may use for planning and administering the use of funds under this title an
amount not to exceed 10 percent of the funds payable to such State under this title for a
fiscal year; and
(B) the State will pay from non-Federal sources the remaining costs of planning and
administering the program assisted under this title and will not use Federal funds for such
remaining cost (except for the costs of the activities described in paragraph (16));
(10) provide that such fiscal control and fund accounting procedures will be established as
may be necessary to assure the proper disbursal of and accounting for Federal funds paid
to the State under this title, including procedures for monitoring the assistance provided
under this title, and provide that the State will comply with the provisions of chapter 75 of
title 31, United States Code (commonly known as the "Single Audit Act");
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SFY-18-L Attachment #4
(11) permit and cooperate with Federal investigations undertaken in accordance with
section 2608;
(12) provide for timely and meaningful public participation in the development of the plan
described in subsection (c);
(13) provide an opportunity for a fair administrative hearing to individuals whose claims for
assistance under the plan described in subsection (c) are denied or are not acted upon
with reasonable promptness; and
(14) cooperate with the Secretary with respect to data collecting and reporting under
section 2610.
(15) * beginning in fiscal year 1992, provide, in addition to such services as may be offered
by State Departments of Public Welfare at the local level, outreach and intake functions for
crisis situations and heating and cooling assistance that is administered by additional
State and local governmental entities or community-based organizations (such as
community action agencies, area agencies on aging and not-for-profit
neighborhood-based organizations), and in States where such organizations do not
administer functions as of September 30, 1991, preference in awarding grants or contracts
for intake services shall be provided to those agencies that administer the low-income
weatherization or energy crisis intervention programs.
* This assurance is applicable only to States, and to territories whose annual regular
LIHEAP allotments exceed $200,000. Neither territories with annual allotments of $200,000
or less nor Indian tribes/tribal organizations are subject to Assurance 15.
(16) use up to 5 percent of such funds, at its option, to provide services that encourage and
enable households to reduce their home energy needs and thereby the need for energy
assistance, including needs assessments, counseling, and assistance with energy vendors, and
report to the Secretary concerning the impact of such activities on the number of households
served, the level of direct benefits provided to those households, and the number of households
that remain unserved.
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SFY-18-L Attachment #4
Plan Attachments
PLAN ATTACHMENTS
The following documents must be attached to this application
Delegation Letter is required if someone other than the Governor or Chairman Certified this Report.
Heating component benefit matrix, if applicable
Cooling component benefit matrix, if applicable
Minutes, notes, or transcripts of public hearing(s).
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SFY-18-L Attachment #4
Attachment 5A
Allowable measures for Low-Income Home Energy Assistance Program (LIHEAP) will include
but not limited to:
• air /envelope sealing
• duct sealing
• Insulation
• base load measures
• HVAC Systems
• Refrigerators
• Gas Stove with high CO readings
• Domestic Water heaters (Gas, Electric or Propane)
• weather-stripping of doors and windows
• health and safety needs of clients
Existing gas kitchen ranges which, because of advanced age and deteriorated condition and which
show unsafe levels of carbon monoxide, must be replaced with a range that has electronic
intermittent ignition features and must comply with all applicable codes for gas kitchen ranges.
If conversion from propane to electric range is needed, prior approval is required from the Arizona
Department of Housing Conversion.
As gas domestic hot water heaters, especially tankless units, tend to be more efficient and cheaper
to operate than electric, conversion from electric water heating to natural gas water heating where
the natural gas service is available to the property line is an allowable measure only if the
household size is two or more occupants.
Conversion of propane heating with A/C to a Heat Pump shall be allowable, but only with prior
approval from the ADOH.
Conversion of propane heating to electric heat resistances shall be allowable, but only with prior
approval from the ADOH.

SFY-18-L Attachment #4
Arizona Cooling Component Benefit Matrix 2017
Payment guidelines are based upon income, energy burden and energy need. Priority points are
given to households with the lowest income, highest energy burden and energy need. Households,
which meet these criteria, are eligible for higher benefits.
1. Poverty: Based on 60 percent of State Median Income for household sizes
of one through six. For households of seven or more percentages will be
based on 150 percent of the Federal Poverty guidelines.
Percent of Poverty Points Applied
0% - 25% 5 points
26% - 50% 4 points
51% - 50% 3 points
76% - 100% 2 point
2. Energy Burden
Percent of Energy Burden Points Applied
5% - or less 0 points
6% - 10% 3 points
11% - 15% 4 points
16% - 20% 5 points
21% - Higher 6 points
3. Energy Need
Percent of Energy Need Points Applied
Elderly 1 point
Disabled 1 point
Child age 6 and under in Household 1 point
Working Poor 1 point
Total Points Applied Payment Levels
1 - 2 $ 75 - $160 maximum
3 - 6 $125 - $320 maximum
7 - 11 $175 - $480 maximum
12 - 15 $225 - $640 maximum

SFY-18-L Attachment #4
Arizona Heating Component Benefit Matrix 2017
Payment guidelines are based upon income, energy burden and energy need. Priority points are
given to households with the lowest income, highest energy burden and energy need. Households,
which meet these criteria, are eligible for higher benefits.
1. Poverty: Based on 60 percent of State Median Income for household sizes
of one through six. For households of seven or more percentages will be
based on 150 percent of the Federal Poverty guidelines.
Percent of Poverty Points Applied
0% - 25% 5 points
26% - 50% 4 points
51% - 50% 3 points
76% - 100% 2 point
2. Energy Burden
Percent of Energy Burden Points Applied
5% - or less 0 points
6% - 10% 3 points
11% - 15% 4 points
16% - 20% 5 points
21% - Higher 6 points
3. Energy Need
Percent of Energy Need Points Applied
Elderly 1 point
Disabled 1 point
Child age 6 and under in Household 1 point
Working Poor 1 point
Total Points Applied Payment Levels
1 - 2 $ 75 - $160 maximum
3 - 6 $125 - $320 maximum
7 - 11 $175 - $480 maximum
12 - 15 $225 - $640 maximum

Attachment 2
FFY 2018 LIHEAP State Plan
A draft of the FFY 2018 State Plan is included for review. Please provide any comments on the attached draft by April 28, 2018.
Workgroups for the FFY 2018 State Plan, which took place December 7, 2016 and January 25 and March 7, 2017, in addition to input from the Arizona Department of Housing,
resulted in the following changes for FFY 2018:
LIHEAP FFY 2018 State Plan Draft Matrix
Section Plan Modifications CAP Network’s Comment DES Response/Changes
Section 1: Error correction in 1.3:
Program Unchecked box for Cooling Assistance
Components
Checked the box for Other: Support a year-
round crisis assistance program that includes
heating and cooling.
Section 2: 2.3 Added text to explain exception to
Heating eligibility calendar for elderly participants in
Assistance recertification programs.
Section 3: 3.3 Added text to explain exception to
Cooling eligibility calendar for elderly participants in
Assistance pilot programs.
Section 5: Changed all income guidelines to 200% of
Weatherization FPL regardless of household size.
Assistance
Under 5.5, Checked the box marked “Other,”
and added explanatory text: “Weatherization
Measures are not subject to DOE Savings to
Investment Ration Standards.”
Deselected the checkboxes in the next item,
which were covered by the above change.

LIHEAP FFY 2018 State Plan Draft Matrix
Section 14: 14.3 Removed United Way of Pinal County
Leveraging
Incentive
Program
Section 17: 17.4 Added language to allow Service
Program Providers to verify Citizenship/Legal
Integrity Residency Status with the State
eligibility/management system (e.g. SNAP,
TANF).
17.5 Changed wording in existing sentence
for clarity. Added language to allow a
participant statement to be used at agency
discretion as verification for income when the
client has attempted but is unable to provide
the verification, no other source of verification
is available, and agency staff have attempted
to assist in obtaining the verification on behalf
of the client. When a partial month of check
stubs is available, the documents available
will be used to calculate the income received
during the period lacking documentation.
Checked the box for Computer data matches
and Income information matched against
state computer system (e.g. SNAP, TANF).
2