FISCAL YEAR or CALENDAR YEAR										FY/ CY 2010
2010 BIA FINANCIAL ASSISTANCE & SOCIAL SERVICE PROGRAM REPORT FORM
	TRIBE/AGENCY FIRST QUARTER		SECOND QUARTER		THIRD QUARTER		FOURTH QUARTER		END-OF-YEAR STATUS
	Actual		Actual		Actual		Actual
	OSG BIA 477 638 (Month-Month-Month)		(Month-Month-Month)		(Month-Month-Month)		(Month-Month-Month)
	A	B	D	E	G	H	J	K	M	N	P	Q
R	Program Component	Actual Persons Served	Expenditures	Actual Persons Served	Expenditures	Actual Persons Served	Expenditures	Actual Persons Served	Expenditures	Total�Actual Persons Served	Expenditures (Sum of All Four Quarters)	Amount Allocated
Surplus or Deficit
	Child Assistance
	Foster Care		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0	Residential Care		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0	Adoption Subsidy		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0	Guardianship Subsidy		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0	Special Needs		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0	Homemaker Services		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0
	Adult Care Assistance
	Homemaker Services		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0	Residential Care (group home)		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0
	General Assistance	0	$ - 0	0	$ - 0	0	$ - 0	0	$ - 0	0	$ - 0	$ - 0
$ - 0	Employable									0
	Unemployable									0
	Individual Self-Sufficiency Plan (ISP)									0
	ISP Goals Completed									0
	Applications Approved									0
	Applications Disapproved									0
	Burial Assistance		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0	Emergency Assistance		$ - 0		$ - 0		$ - 0		$ - 0	0	$ - 0	$ - 0
$ - 0
	IIM Accounts
	Services									0
	Distribution Plans Processed									0
	Services Only
	Child Protection									0
	Adult Protection									0
	Child and Family Services									0
	Total	0	$ - 0	0	$ - 0	0	$0	0	$ - 0	0	$ - 0	$ - 0
$ - 0638 Tribe/BIA Agency Program Certification (Only)					OSG or 477 Program Certification (Only)
TRIBE/AGENCY (Insert name/Title):			DATE:	TRIBE (Insert Name/Title):						DATE:
AGENCY SUPERINTENDENT (Certify)			DATE:	OFFICE OF SELF GOVERNANCE or OFFICE OF INDIAN ENERGY AND ECONOMIC DEVELOPMENT (Certify)						DATE:
REGIONAL SOCIAL WORKER (Certify)			DATE:	26/8/2010

INSERT NAME OF TRIBE/BIA AGENCY HERE

FY/CY 2010

SECTION II: THE NARRATIVE

Instructions: Complete a narrative for your program by answering the following questions.

QUESTION #1: (1-2 paragraphs) Briefly describe the community(ies) or tribe(s) that you provide services to (i.e. any information that you feel will help us understand more about your program, include the following information: Tribes served, counties served, location, climate, demographics, culture, economy, employment, housing, crime, abuse statistics).

Type Here.

QUESTION #2: (1-2 paragraphs). Briefly describe your program: What type of delivery method is your program (477, 638, BIA Agency, Self Governance, or a mixture), the staffing, caseload per staff, types of services provided, and any information that you feel will help us understand your program).

Type Here.

QUESTION #3: (1-2 paragraphs). Discuss the statistical analysis (BIA Financial Assistance & Social Service Program Report Form), identify carryover from FY/CY 2009, identify carryover from current reporting year (FY/CY 2010), and discuss unmet need (SHORTFALL) for FY/CY 2010.

Type Here.

QUESTION #4: (1-2 paragraphs). Compare the current year statistical report to the previous year report. Discuss changes in the number of persons served - increases or decreases in services/ case loads, and funds expended. If different, why? (i.e. natural disaster, inflation, program funds reduced). How might your program be impacted should a shortage of funds occur in the FY/CY 2011? (i.e. cite programs that were discontinued or areas where services were reduced due to a shortage of funds).

Type Here.

QUESTION #5: Please provide any additional comments or recommendations.

Type Here

26/8/2010