2024 AFCSP Budget Report F-21343 (10/2023)

Division of Public Health

Alzheimer's Family Caregiver Support Program (AFCSP) 2024 Budget

Please respond to each question, using the previous year's budget as a guide for completing this report. Completion of this form satisfies the requirements under Wis. Admin. Code § DHS 68.05 for a distinct program budget for the AFCSP.

You will not be able to start, stop, and then resume data entry into this report. You may want to print this report so you can gather the necessary information before beginning the data entry.

* denotes a required field

1. County, counties, or tribe included in budget:*

2. Name of designated AFCSP lead agency:*

3. Your name:*

4. Your email address:*

5. Your phone number (include area code):*

6. 2024 allocation in dollars:* This question requires a valid currency format.

7. Number of households anticipated to be enrolled and served in the coming year:* This question requires a valid number format.

Planned distribution of funds by purpose, in dollars ($) and percents (%) (Wis. Admin. Code § 68.06)

Please check your math before you submit.
County programs are required to spend a minimum of 40% of the agency's AFCSP allocation to provide respite to caregivers of people diagnosed with dementia. Tribes are exempt from the 40% respite requirement.
No more than 10% can be claimed for program administration.
Estimates are allowed for the categories in question 9, but be aware actual expenses for each type of respite will be required as part of the AFCSP Fiscal Report.

8. Dollars planned for respite services:* This question requires a valid currency format.

9. Amount planned for each type of respite:* This question requires a valid currency format.

Adult day services
Caregiver self-care
Homemaker/chores
In-home general respite
In-home personal care
Overnight facility respite
Other respite service(s)

10. Percent planned for all respite services:* This question requires a valid percent format.

11. Dollars planned for purchasing other goods and services:* This question requires a valid currency format.

12. Dollars planned for the development of new or expanded services:*
(Note: If any expenditures are planned, please complete item 23.) This question requires a valid currency format.

13. Dollars planned for outreach activities and public awareness:* This question requires a valid currency format.

14. Dollars planned for support group development or assistance:* This question requires a valid currency format.

15. Dollars planned for staff training and case management:* This question requires a valid currency format.

16. Dollars planned for program administration:* This question requires a valid currency format.

17. Percent planned for program administration (maximum 10%):* This question requires a valid percent format.

Methods for fund distribution

18. Do you plan to make payments to service providers for direct care as a method of distributing these funds? (Wis. Admin. Code § DHS 68.09)*

19. Do you plan to make payments to households of persons with Alzheimer's Disease (i.e., cash grant for agreed-upon service/goods)? (Wis. Admin. Code § DHS 68.09)*

20. Indicate the county's or tribe's maximum amount payable in the calendar year to or on behalf of any participating person.*

21. If maximum amount payable in question 20 is less than $4,000, indicate the amount of maximum:* This question requires a valid currency format.

22. Briefly describe any limitations being placed on goods and services that are to be provided, purchased, or contracted. See Wis. Admin. Code § DHS 68.06(2)(b) for list of possible services. Generally speaking, all services should be made available to AFCSP enrollees and approved based on the family's needs and preferences. If no limitations, indicate none.*

23. Briefly describe any new programs or expanded services planned for the coming year, see definitions under Wis. Admin. Code §§ DHS 68.02(8) and (13). Indicate if this is year one, two, or three of the program development or expansion.*

24. Explain your program's waiting list policy, including how many families have been told they must wait for services.*

25. Explain how your program, aging unit, and/or Aging and Disability Resource Center (ADRC) will provide outreach to families living with or newly diagnosed with Alzheimer's or dementia. Include specific plans for marketing, collaborating with your agency’s dementia care specialist, and providing education to families and community partners about the benefits of enrolling in AFCSP.