Title V: Community Prevention Grants Program
Community Self-Evaluation Workbook




This Form collects basic information about you, the Title V grant recipient, and the prevention funding you received.


  • Do not write on the original Form. Make copies of Form 1-1. You will need one copy of this Form for each separate Title V grant awarded to your community.

  • Get a copy of your Title V grant application and the grant award document you received from the State. Most of the information required for Form 1-1 can be found in these two sources.

1. Title V Target Community

  1. Community Name: Fill in the name of the target community for which Title V grant funds will be used. Use the same community name that was written in your grant application.

  2. State: Provide the two letter State abbreviation for your State.

2. Title V Grant Information

  1. Grant Recipient: Name the unit of general local government (e.g., city, county, township, borough, parish, tribe) that is the official recipient of the Title V grant award.

  2. Address: Provide the address, including the office number, street, city, State, and zip code of the grant recipient described above.

  3. Point of Contact: Indicate the name and title of a point of contact at the grant recipient organization. This person should hold responsibility for administering Title V funds.

  4. Phone Number and Fax Number: List the phone number (P) and the fax number (F) of the point of contact. Include the area code.

  5. State Award Number: Indicate the unique identifying number assigned by the State Agency to your grant project.

  6. Date Awarded: Enter the date the State Agency awarded the grant to your community.

  7. Total Award Amount: List the total dollar amount of Title V funds awarded from the State to your community for the duration of the grant. Do not include matching resources in this space.

  8. Funding Period: Enter the beginning and ending dates for the funding period of your grant. This funding period may range from 12 to 36 months. If your community submitted a single application and received a 3-year grant, then complete one copy of Form 1-1 and enter a funding period reflecting 36 months. If your community was required to submit a new application each year and was awarded three separate Title V grants, then complete three copies of Form 1-1, each with a 12-month funding period.

3. Matching Resources for Title V Grant

The terms of the Title V grant require a 50-percent match of resources, either in cash or in kind, and the State or the unit of general local government are responsible for providing the match. Describe your community's matching resources in Table 3. Attach an additional page if you have more than five sources of matching funds.

  1. Source: List the name of each provider of matching resources. The source may be a State agency or unit of general local government. Be specific in identifying the funding source (e.g., State Department of Juvenile Justice Formula Grants Program, County Government At-Risk Youth Program).

  2. Type: Describe the resource or service provided. Resource types may include: cash, staff time, office space, equipment, transportation, professional services, etc.

  3. Value: Provide the dollar amount of each cash award and the estimated value of the goods and services received for each in-kind contribution. Enter the total value of matching resources in the bottom row. (This total should equal at least 50 percent of your total Title V grant.)

  4. Period: List the beginning and end dates of the funding period for the matching resource.

4. Other Non-Title V Funding Sources for Prevention Activities in the Target Community

In addition to the Title V grants and matching resources, many communities may also be recipients of other Federal, State, local, or private funding that supports interagency planning, coordination, and service delivery for prevention programs. Examples of non-Title V funding sources include: U.S. Department of Health and Human Services: Family Preservation and Support Services; CSAP Community Partnership Grants; Department of Education: Drug Free Schools Program; Metropolitan Life Foundation; XYZ Corporation Community Development Campaign. Using the same instructions explained above for Table 3, list other significant prevention funding sources in your community, along with the resource type, value, and period. Be as specific as possible. Keep in mind that only funds or in-kind resources from the State or unit of general local government may qualify as match funding under Title V. But in order to understand your full prevention picture, it is also important to identify what other resources are available for prevention activities in your community.

You may receive outside funding before or after the award of the Title V grant. If, during the course of the Title V grant period, additional prevention funding is awarded to the target community, be sure to add the relevant information to the table. (Attach an additional page if you have more than three sources of non-Title V funding sources.)

5. Additional Grant or Resource Information

Use this space or attach extra pages to provide any additional information, special circumstances, or other comments related to your grant award and other prevention funding resources in your community.

FORM 1-1 (Wordperfect format)