MOE_rpt

Attachment B
Annual Report on State Maintenance-of-Effort Programs: Form ACF-204
State

Fiscal Year

Date Submitted__________________________

Provide the following information for EACH PROGRAM (according to the nature of
the benefit or service provided) for which the State claims MOE expenditures. Complete
and submit this report in accordance with the attached instructions.
1.

Name of Benefit or Service Program

2. Description of the Major Program Benefits, Services, and Activities:

3. Purpose(s) of Benefit or Service Program:

4. Program Type. (Check one)
This Program is operated under the TANF program.
This Program is a separate State program.

1

5.

Description of Work Activities (Complete only if this program is a separate State
program):

6.

Total State Expenditures for the Program for the Fiscal Year: _________________

7.

Total State MOE Expenditures under the Program for the Fiscal Year:
_________________

8.

Total Number of Families Served under the Program with MOE Funds:

This last figure represents (check one):
The average monthly total for the fiscal year.
The total served over the fiscal year.

9.

Financial Eligibility Criteria for Receiving MOE-funded Program Benefits or Services:

2

10.

Prior Program Authorization: Was this program authorized and allowable under prior law?
(check one)
Yes

11.

No

Total Program Expenditures in FY 1995: _________________________
(NOTE: provide only if response on question 10 is No)

This certifies that all families for which the State claims MOE expenditures for the fiscal
year meet the State's criteria for "eligible families."

SIGNATURE:

NAME:

TITLE:

Approved OMB No. 0970-0199 Form ACF-204, expires 6/30/2002.

3