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pdfSSP MOE DATA REPORT - SECTION 1
DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER THE
STATE SEPARATE PROGRAMS
GENERAL INFORMATION
1.
State FIPS Code
2.
County FIPS Code
3.
Reporting Month
4.
Year
Y
Stratum
Month
Y
Y
Y
M
M
FAMILY LEVEL DATA
8.
5.
Case Number - Separate State MOE
6.
ZIP Code
7.
Disposition
Number of
Family
Members
9.
Type of Family
for Work
Participation
ASSISTANCE RECEIVED BY THE FAMILY
10.
15.
Has the Family Received Assistance
Under a State (Tribal) TANF Program
Within the Past Six Months
Receives Subsidized
Child Care
16.
11.
Receives Subsidized
Housing
Amount of Subsidized
Child Care
OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 209
12.
Receives Medical
Assistance
18.
17.
Amount of Child Support
13.
Receives Food
Stamps
14.
Amount of Food Stamps
Assistance
Amount of the Family's
Cash Resources
SSP-MOE DATA REPORT - SECTION 1
Page 1
ASSISTANCE PROVIDED UNDER STATE SEPARATE PROGRAMS, BY TYPE
19. Cash and Cash Equivalent
A.
Amount
B.
Number of Months
20. Child Care
A.
Amount
B.
21. Transportation
Number of
Children Covered
C.
Number of
Months
A.
Amount
B.
22. Transitional Services
A.
Amount
B.
Number of Months
23. Other Assistance
Number of Months
A.
Amount
B.
Number of Months
REASON FOR AND AMOUNT OF REDUCTION IN ASSISTANCE
24. Reason for and Amount of Reduction In Assistance:
A. Sanctions:
iii.
i.
Total Dollar Amount of
Reduction Due to
Sanctions
ii.
OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 209
Work
Requirements
Sanction
Family Sanction for
an Adult with No
High School
Diploma or
Equivalent
vi.
iv.
Sanction for
Teen Parent
Not Attending
School
SSP-MOE DATA REPORT - SECTION 1
v.
Noncooperation in
Child Support
Failure to
Comply with
Individual
Responsibility
Plan
vii. Other
Sanction
Page 2
B.
25.
Recoupment of Prior
Overpayment
C.
Other:
i.
Total Dollar Amount of Reductions
Due to Other Reasons (excludes
Sanctions and Recoupment
iii.
ii.
Family Cap
Reduction Based on
Length of Receipt of
Assistance
iv.
Other, Non-sanction
Waiver Evaluation Research Group
PERSON LEVEL DATA
ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS
26.
Adult
Family
Affiliation
27.
Non-Custodial Parent
Indicator
28.
Y
Date of Birth (Age)
Y
Y
Y
M
29
M
D
.Social Security Number
D
1
-
-
2
-
-
3
-
-
4
-
-
5
-
-
6
-
-
OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 209
SSP-MOE DATA REPORT - SECTION 1
Page 3
30. Race/Ethnicity
Adult
A.
Ethnicity
Race
Hispanic or Latino
B.
American Indian of
Alaska Native
C.
Asian
D.
Black or African
American
C.
Receives Aid
Under Title
XIV-APDT
D.
Receives Aid
Under Title
XVI-AABD
E.
Native Hawaiian or
Pacific Islander
F. White
1
2
3
4
5
6
31.
Adult
Gender
32.
Receives Disability Benefits
A.
Receives
Federal
Disability
Insurance
Benefits
B.
Receives
Benefits Based
on Federal
Disability
Status
E.
Receives Aid
Under Title
XVI-SSI
33.
Marital Status
1
2
3
4
5
6
OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 209
SSP-MOE DATA REPORT - SECTION 1
Page 4
34.
Adult
Relationship to
Head of
Househol
d
35.
Parent
with
Minor
Child in
Family
36.
Needs of
a
Pregnant
Woman
37.
Educational
Level
38.
Citizenship /
Alienage
39.
Cooperation in
Child
Support
40.
Employment
Status
.41
WorkEligible
Individual
Indicator
.42
Work
Participation
Status
1
2
3
4
5
6
ADULT WORK PARTICIPATION ACTIVITIES
43.
Adult
Unsubsidized
Employment
44.
Subsidized Private
Sector
45.
Subsidized Public
Sector
46.
Work Experience
47.
On-the-Job Training
1
2
3
4
5
6
OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 209
SSP-MOE DATA REPORT - SECTION 1
Page 5
52.
51.
48.
Job Search and Job
49.
Readiness Assistance
Community Service
Programs
53.
Satisfactory School
Attendance for Individuals
with No High School
Diploma or Certificate of
High School Equivalency
54.
Adult
50.
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
55.
Additional Work Activities
Permitted Under Waiver
Demonstration
56.
Other Work
Activities
57.
Required Hours of
Work Under Waiver
Demonstration
1
2
3
4
5
6
OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 209
SSP-MOE DATA REPORT - SECTION 1
Page 6
AMOUNT OF INCOME, BY TYPE
58.
Adult
Amount of
Earned
Income
59.
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
60.
Child
Family
Affiliation
61.
Date of Birth (Age)
Y
Y
Y
Y
M
62.
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 - 209
SSP-MOE DATA REPORT - SECTION 1
Page 7
63 Race/Ethnicity
Child
A.
Ethnicity
Race
Hispanic or Latino
B.
American Indian of
Alaska Native
C.
Asian
D.
Black or African
American
66.
Relationship to
Head of
Household
E.
Native Hawaiian or
Pacific Islander
F. White
1
2
3
4
5
6
7
8
9
10
Child
64.
Gender
65.
Receives Disability Benefits:
A.
Receives Benefits
Based on Federal
Disability Status
B.
Receives Aid Under
Title XVI-SSI
67.
Parent with
Minor Child in
the Family
68.
Educational
Level
1
2
3
4
5
OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 209
SSP-MOE DATA REPORT - SECTION 1
Page 8
Child
64.
Gender
69.
Citizenship /
Alienage
65.
Receives Disability Benefits:
A.
Receives Benefits
Based on Federal
Disability Status
66.
B.
Receives Aid Under
Title XVI-SSI
Relationship to
Head of
Household
6
7
8
9
10
Child
1
2
3
4
5
6
7
8
9
10
70.
Amount of Unearned Income
A.
SSI
B.
Other Unearned Income
67.
Parent with
Minor Child in
the Family
68.
Educational
Level
| File Type | application/pdf |
| File Title | Microsoft Word - ssprpt1frev.doc |
| Author | ajsaulnier |
| File Modified | 2006-06-13 |
| File Created | 2006-06-13 |