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Intended Use Plan - SSBG

ICR 202606-0970-008 · OMB 0970-0234 · Object 169886900.

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File Type	application/pdf
File Title	Intended Use Plan - SSBG
Last Modified By	Mozilla/5.0 (Windows NT 10.0; Win64; x64) AppleWebKit/537.36 (KH
File Modified	2026-05-06
File Created	2026-05-06
Conversion State	complete

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OMB Control Number: 0970-0234
Expiration Date: 3/31/2027

Intended Use Plan
Use this form to complete and submit your State's/Territory's Intended Use Plan for the selected reporting year.

If you experience issues completing or submitting the Intended Use Plan, please contact the SSBG Technical Team at [email protected]
(mailto:[email protected]).

Year
2028
Group: California
Year: 2028
Status: In Process
Export Full Report (/Rpt/IupCom

General Information

Administrative Operations

Program Planning

Appendices

State/Territory Official Contact Information
First Name

Last Name

Title

Agency

Street 1

Street 2

Program Operations

Assurances

City

State/Territory
Select A State/Territory
Zip

Phone Number

SSBG Contact Information
First Name

Last Name

Title

Agency

Street 1

Street 2

City

State/Territory
Select A State/Territory
Zip

Phone Number

General Information
SSBG Award from Previous Year:

SSBG Expenditures Planned for Current Year:

TANF Funds Transferred into SSBG:

Consolidated Block Grant Funds Included in SSBG Budget:
Yes

Provide the amount of funding for each applicable funding source for the consolidated block grant.

SSBG Carryover Funding from the Previous Year:
Yes

Provide the carryover amount of funding for each applicable funding source for the previous year.

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For technical assistance, please contact the SSBG Technical Team at [email protected] (mailto:[email protected]).
Vulnerability Disclosure Policy (https://www.hhs.gov/vulnerability-disclosure-policy/index.html)
2026 - SSBG

Submit...

OMB Control Number: 0970-0234
Expiration Date: 3/31/2027

Intended Use Plan
Use this form to complete and submit your State's/Territory's Intended Use Plan for the selected reporting year.

If you experience issues completing or submitting the Intended Use Plan, please contact the SSBG Technical Team at [email protected]
(mailto:[email protected]).

Year
2028
Group: California
Year: 2028
Status: In Process
Export Full Report (/Rpt/IupCom

General Information

Administrative Operations

Appendices

Administrative Operations
Administering Agency

Location

Mission/Goals of Agency

Description of Financial Operations System

Program Planning

Program Operations

Assurances

Save

Cancel

Submit...

OMB Control Number: 0970-0234
Expiration Date: 3/31/2027

Intended Use Plan
Use this form to complete and submit your State's/Territory's Intended Use Plan for the selected reporting year.

If you experience issues completing or submitting the Intended Use Plan, please contact the SSBG Technical Team at [email protected]
(mailto:[email protected]).

Year
2028
Group: California
Year: 2028
Status: In Process
Export Full Report (/Rpt/IupCom

General Information

Administrative Operations

Program Planning

Program Operations

Assurances

Appendices

Program Planning
Planning of Distribution and Use of Funds
Describe the planning process for determining the State's/Territory's use and distribution of SSBG funds.

Describe the Characteristics of Individuals to be Served
Include definitions for child, adult, and family; eligibility criteria; and income guidelines.

Public Inspection of Pre-Expenditure Report
Describe how the State/Territory made available for public inspection and comment the current Pre- Expenditure Report or revision to the report.
Supporting documentation for public inspection is also required. (See V. Appendices, Appendix A: Documentation of Public Hearing).

Save

Cancel

Submit...

OMB Control Number: 0970-0234
Expiration Date: 3/31/2027

Intended Use Plan
Use this form to complete and submit your State's/Territory's Intended Use Plan for the selected reporting year.

If you experience issues completing or submitting the Intended Use Plan, please contact the SSBG Technical Team at [email protected]
(mailto:[email protected]).

Year
2028
Group: California
Year: 2028
Status: In Process
Export Full Report (/Rpt/IupCom

General Information

Administrative Operations

Program Planning

Appendices

Program Operations
Click “Add service category” to add only the categories your State/Territory provides.
No service categories have been added yet.

Add / Edit Service Category
Service Category (use uniform
definition)
SSBG Goal

Description of Services

-- Select a service category --

Program Operations

Assurances

Description of Recipients
(eligibility considerations)

Method of Delivery and
Geographic Area

Partnering State/Territory
Agency

Subgrantee / Service Providers

Save service category

Save

Cancel

Submit...

OMB Control Number: 0970-0234
Expiration Date: 3/31/2027

Intended Use Plan
Use this form to complete and submit your State's/Territory's Intended Use Plan for the selected reporting year.

If you experience issues completing or submitting the Intended Use Plan, please contact the SSBG Technical Team at [email protected]
(mailto:[email protected]).

Year
2028
Group: California
Year: 2028
Status: In Process
Export Full Report (/Rpt/IupCom

General Information

Administrative Operations

Program Planning

Program Operations

Assurances

Appendices

Section A: The following certifications are required for eligibility to receive Social Service Block Grant (SSBG) or Consolidated Block Grant
(CBG) funds. Please indicate that you have read, understand, and agree to certify the following:
1. Temporary Assistance to Needy Families (TANF) Transfer - Administration
The state/territory hereby certifies that no more than 10 percent of their TANF Block Grant will be transferred to the SSBG/CBG to serve
children and families with incomes of 200% of the federal poverty threshold or less. The transferred TANF funds and regular SSBG or CBG
funds granted are to be spent in the fiscal year awarded or the subsequent year. Relevant statutes: Section 404(d)(3)(A) and (B) of the
Social Security Act. Grant recipients also are subject to the 2- year time limiting provisions contained in 45 CFR Part 95.
2. TANF Transfer Limit (200% of Federal Poverty Level)
The state/territory hereby certifies that funds transferred from the TANF block grant to the SSBG or CBG will be expended exclusively for
programs and services provided to children or families whose income is less than or equal to 200% of the federal poverty guidelines, as
updated annually by the U.S. Department of Health and Human Services (HHS), applicable to the size of the family unit served. These
funds will be used for purposes authorized under Title XX of the Social Security Act.
3. Grant and Federal Financial Reports
The applicant certifies compliance with all applicable federal fiscal reporting requirements, grant regulations, and cost principles, including
those set forth in 2 CFR Part 200 (Uniform Guidance). The applicant affirms adherence to all required certifications and assurances
associated with federal financial assistance, including those maintained through SAM.gov and incorporated into the Notice of Award. The
applicant agrees to maintain adequate financial management systems, internal controls, and records to ensure proper stewardship and
accountability of funds under the SSBG and related CBG programs. The applicant further certifies that all information provided is true and
complete and acknowledges that failure to comply may result in enforcement actions in accordance with federal law.
4. No Lobbying

The applicant certifies that no federal appropriated funds have been or will be used to influence or attempt to influence federal officials in
connection with this award. The applicant further agrees to disclose any such activities funded with non-federal resources by submitting
Standard Form-LLL, as required. The applicant will include this certification in all subawards and ensure subrecipients comply accordingly.
The applicant acknowledges that this certification is a material representation and that failure to comply may result in civil penalties under 31
U.S.C. § 1352.
5. Debarment, Suspension
The state/territory certifies that the Authorized Official, principals and delegates are not debarred, suspended, or otherwise ineligible for
federal transactions, and have not engaged in disqualifying misconduct such as fraud or criminal offenses. The signer affirms the accuracy
of this representation, agrees to notify the government of any changes, and understands that false certification may result in penalties
including suspension or debarment.
6. Drug-Free Workplace
By applying for and accepting federal funds, the Authorizing Official (or their delegate) for the state/territory certifies that the state/territory
will provide a drug-free workplace, as per the Drug Free Workplace Act of 1988. Further, the Authorizing Official/delegate certifies that the
state/territory will comply with the requirements regarding agency notification for criminal drug statutes. Failure to comply with these
requirements may be cause for debarment.
7. Smoke-Free Environment
The SSBG Smoke-Free Workplace certification, formally known as the Certification Regarding Environmental Tobacco Smoke, is a required
compliance document under the Pro-Children Act of 1994 (Public Law 103-227). It prohibits smoking in indoor facilities where federally
funded, routine services are provided to children (e.g., day care, education, libraries).
8. Anti-Discrimination
The Applicant certifies that the state/territories, and its subrecipients and contractor organizations will comply with all federal statutes
relating to nondiscrimination, including Title VI of the Civil Rights Act of 1964 (race, color, national origin), Section 504 of the Rehabilitation
Act of 1973 (disability), and the Age Discrimination Act of 1975. The Applicant further assures that all program information and services will
be available in appropriate alternative formats to meet the requirements of persons with disabilities, in accordance with the Americans with
Disabilities Act.
9. Civil Rights Provisions
The Authorized Official (or delegate) certifies that the state or territory, and their subrecipients and contractor organizations will comply with
all federal statutes relating to nondiscrimination, including Title VI of the Civil Rights Act of 1964 (race, color, national origin), Section 504 of
the Rehabilitation Act of 1973 (disability), and the Age Discrimination Act of 1975. The Applicant further certifies that all program information
and services will be available in appropriate alternative formats to meet the requirements of persons with disabilities, in accordance with the
Americans with Disabilities Act. By applying for or accepting federal funds from HHS, recipients certify compliance with all federal
antidiscrimination laws and these requirements and that complying with those laws is a material condition of receiving federal funding
streams. Recipients are responsible for ensuring subrecipients, contractors, and partners also comply.
10. Post-Expenditure Report Requirement
The applicant state or territory authorized official certifies to submit the mandatory Post- Expenditure Report that describes actual expends
for SSBG or CBG funds for the most recently completed fiscal year – no later than 90 days following the end of the fiscal year. A certification
of compliance may be included as part of the annual application process – as an expectation.
Do you understand and agree to certify the certifications above? Please note that those certifications are required for eligibility to
receive SSBG or CBG funding.
Agree

Disagree

If you selected "Disagree", please explain why:

Section B: Please indicate that you have read, understand, and agree to certify the following individually, which are also required for eligibility to
receive SSBG funding:
1. Intended Use Plan, Pre-Expenditure Report and SF 424M

The authorized official certifies submission of the required Intended Use Plan information, data input via the SSBG Portal for the Pre-Expenditure
Plan, and attach a copy of the completed SF 424M to comply with the requirement of this planned use of funds, including the individuals to be
served, and services to be provided, as prerequisites to receiving annual federal funds for the SSBG or CBG for US territories.
Agree

Disagree

2. Audit and Proof of Audit
The applicant certifies compliance with audit requirements under Title XX of the Social Security Act, including Section 2006, and applicable
provisions of 2 CFR Part 200 (Uniform Guidance). The applicant affirms that required audits are conducted in accordance with federal standards
and that any findings are addressed through appropriate corrective actions. A copy of the most recent audit report has been submitted to the
federal program office as an attachment via the SSBG Portal. The applicant acknowledges responsibility for maintaining records and providing
access for federal or authorized review as required.
Agree

Disagree

3. Public comment period
The state or territory’s authorized official/delegate certifies compliance with public notice and comment requirements as under Section 2004 of
Title XX of the Social Security Act and applicable federal regulations, including providing the public a reasonable opportunity to review and
comment on the Intended Use Plan and Pre-Expenditure Report for 10 days prior to submission. The applicant affirms that these documents were
made publicly available for inspection and comment for 10 days in accordance with federal guidance. The applicant further certifies that
documentation of publication and proof of distribution has been completed. Such documentation has been submitted to the federal program office
as an attachment via the SSBG Portal.
Agree

Save

Disagree

Cancel

Submit...

OMB Control Number: 0970-0234
Expiration Date: 3/31/2027

Intended Use Plan
Use this form to complete and submit your State's/Territory's Intended Use Plan for the selected reporting year.

If you experience issues completing or submitting the Intended Use Plan, please contact the SSBG Technical Team at [email protected]
(mailto:[email protected]).

Year
2028
Group: California
Year: 2028
Status: In Process
Export Full Report (/Rpt/IupCom

General Information

Administrative Operations

Program Planning

Program Operations

Assurances

Appendices

Appendices
Please click save after selecting your documents to complete the upload.
1. Form SF-424M
Scanned copy must be uploaded with application
Choose File No file chosen
2. Audit and Proof of Audit
Provide a copy or link to the most recent audit, or a description of the audit that specifies when the audit occurred and summarizes the results of
the audit.
Choose File No file chosen
3. No-Lobbying
Attach a signed copy of this certification.
Choose File No file chosen

4. Public Comment Period
Please upload documentation of publication and proof of distribution.

Choose File No file chosen
5. Debarment, Suspension
Attach a signed copy of this certification.
Choose File No file chosen

6. Civil Rights Provisions
Attach a signed copy of this certification.
(No file uploaded yet)
Choose File No file chosen

7. Drug-Free Workplace
Attach a signed copy of this certification.
Choose File No file chosen

8. Smoke-Free Environment
Attach a signed copy of this certification.
Choose File No file chosen

9. Federal Financial Report (FFR) – SF-425
Scanned copy must be uploaded with the Intended Use Plan
Choose File No file chosen
10. TANF ACF-196R form
Scanned copy must be uploaded with the Intended Use Plan
Choose File No file chosen

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