Data Verification Procedures; Caseload Reduction Documentation Process; Reasonable Cause/Corrective Compliance Documentation Process, TANF Data Report; SSP-MOE Data Report

TANF DATA REPORT - SECTION 1
TANF DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER
THE TANF PROGRAM
GENERAL INFORMATION
2.
1.

County FIPS Code

3.

State FIPS Code

4.

Tribal Code
(For Tribal Use Only)

Reporting Month

5.

Year

Y

Y

Stratum

Month

Y

Y

M

M

FAMILY LEVEL DATA
6.

Case Number - TANF

8.

Funding
Stream

9

Disposition

10.

New Applicant

7.

ZIP Code

11.

Number of
Family Members

12.

Type of Family for Work
Participation

ASSISTANCE RECEIVED BY THE FAMILY
13.

Receives Subsidized
Housing

14.

19.

Amount of Child Support

Receives Medical
Assistance

20.

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

15.

Receives Food
Stamps

16.

Amount of Food Stamps
Assistance

17.

Receives Subsidized
Child Care

18.

Amount of Subsidized
Child Care

Amount of the Family's
Cash Resources

TANF DATA REPORT - SECTION 1

Page 1

ASSISTANCE PROVIDED UNDER STATE (TRIBAL) TANF PROGRAM, BY TYPE
21. Cash and Cash Equivalent
A.

Amount

B.

Number of
Months

22. TANF Child Care
A.

Amount

B.

23. Transportation

Number of
C.
Children Covered

Number of
Months

A.

Amount

24. Transitional Services
A.

Amount

B.

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

B.

Number of Months

B.

Number of Months

25. Other Assistance
Number of
Months

A.

Amount

TANF DATA REPORT - SECTION 1

Page 2

REASON FOR AND AMOUNT OF REDUCTION IN ASSISTANCE
26. Reason and Amount of Reduction in Assistance
A. Sanctions:
i.

B.

Total Dollar
Amount for
Reduction Due to
Sanctions

ii.

Work
Requirements
Sanction

C.

Recoupment of Prior Overpayment

i.

27.

Waiver Evaluation
Experimental Control
Group

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

28.

iii.

Family Sanction
for an Adult with
No High School
Diploma or Equivalent

iv.

Sanction for
Teen Parent
Not Attending
School

v.

Noncooperat
ion with
Child
Support

vi.

Failure to
Comply with
an Individual
Responsibility
Plan

vii. Other
Sanction

Other:
Total Dollar Amount
of Reduction Due to
Other Reasons

ii.

Family Cap

iii.

Reduction Based on
Length of Receipt of
Assistance

Is the TANF Family Exempt from Federal Time Limit Provisions

TANF DATA REPORT - SECTION 1

29.

iv.

Other, Non-sanction

Is the TANF Family a New ChildOnly Family?

Page 3

PERSON LEVEL DATA
ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS
30.

Family
Affiliation

31.

Adult

Non-Custodial
Parent
Indicator

32.

Y

Date of Birth (Age)

Y

Y

Y

M

33.

M

D

Social Security Number

D

1

-

-

2

-

-

3

-

-

4

-

-

5

-

-

6

-

-

34. Race/Ethnicity

Adult

A.

Ethnicity

Race

Hispanic or Latino

B.

American Indian of
Alaska Native

C.

Asian

D.

Black or African
American

E.

Native Hawaiian or
Pacific Islander

F. White

1
2
3
4
5
6

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 1

Page 4

Adult

35.

36.

Receives Disability Benefits

A.

Receives Federal
Disability Insurance
Benefits - OASDI

Gender

B.

Receives Benefits
Based on Federal
Disability Status

C.

Parent with
Minor Child in
the Family

Needs of a
Pregnant
Woman

E.
Receives Aid Under
Title XIV-APDT

D.

Receives Aid Under
Title XVI-AABD

Receives Aid
Under Title
XVI-SSI

1
2
3
4
5
6

39.
38.
Adult

37.

Marital Status

Relationship to Head
of Household

40.

41.

Educational Level

42.

Citizenship / Alienage

1
2
3
4
5
6

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 1

Page 5

43.
Adult

Cooperation
in Child
Support

44.

Number of Months
Countable Toward
Federal Time Limit

45.

Number of Countable
Months Remaining
Under State's (Tribe's)
Time Limit

46.

Is Current
Month Exempt
From State's
(Tribe's) Time
Limit

47.

Employment Status

48.

Work-Eligible
Individual
Indicator

49. Work
Participation

1
2
3
4
5
6

ADULT WORK PARTICIPATION ACTIVITIES
50.
Adult

Unsubsidized
Employment

51.

Subsidized Private
Sector Employment

52.

Subsidized Public
Sector Employment

53.

Work Experience

54.

On-the-Job Training

1
2
3
4
5
6

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 1

Page 6

59.
58.
55.

Job Search and Job
56.
Readiness Assistance

Community Service
Programs

60.

Satisfactory School
Attendance for Individuals
with No High School
Diploma or Certificate of
High School Equivalency

61.

Adult

57.

Vocational
Educational Training

Job Skills Training
Directly Related to
Employment

Education Directly Related to
Employment for Individuals with No
High School Diploma or Certificate of
High School Equivalency

1
2
3
4
5
6

Adult

Providing Child Care
Services to an Individual
Who is Participating in a
Community Service
Program

62.

Additional Work Activities
Permitted Under Waiver
Demonstration

64.
63.

Other Work
Activities

Required Hours of
Work Under Waiver
Demonstration

1
2
3
4
5
6

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 1

Page 7

AMOUNT OF INCOME, BY TYPE
65.
Adult

Amount of
Earned
Income

66.

Amount of Unearned Income

A.

Earned
Income Tax
Credit - EITC

E.
B.

Social
Security

D.
C.

SSI

Worker's
Compensation

Other
Unearned
Income

1
2
3
4
5
6

CHILD CHARACTERISTICS
67.
Child

Family
Affiliation

68.

Date of Birth (Age)

Y

Y

Y

Y

M

69.
M

D

Social Security Number

D

1

-

-

2

-

-

3

-

-

4

-

-

5

-

-

6

-

-

7

-

-

8

-

-

9

-

-

10

-

-

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 1

Page 8

70. Race/Ethnicity

Child

A.

Ethnicity

Race

Hispanic or Latino

B.

American Indian of
Alaska Native

C.

Asian

D.

Black or African
American

E.

Native Hawaiian or
Pacific Islander

F. White

1
2
3
4
5
6
7
8
9
10

Child

71.

Gender

72.

Receives Disability Benefits:

A.

Receives Benefits
Based on Federal
Disability Status

B.

Receives Aid
Under Title
XVI-SSI

73.

Relationship to
Head of
Household

74.

Parent with
Minor Child in
the Family

75.

Educational
Level

1
2
3
4
5

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 1

Page 9

Child

71.

Gender

72.

Receives Disability Benefits:

A.

Receives Benefits
Based on Federal
Disability Status

B.

Receives Aid
Under Title
XVI-SSI

73.

Relationship to
Head of
Household

74.

Parent with
Minor Child in
the Family

75.

Educational
Level

6
7
8
9
10
76.
Child

Citizenship /
Alienage

77.

Amount of Unearned Income

A.

SSI

B.

Other Unearned Income

1
2
3
4
5
6
7
8
9
10

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 1

Page 10