ACF-196T Tribal TANF Report Form

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U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR CHILDREN AND FAMILIES

TRIBAL TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) ACF - 196T FINANCIAL REPORT
TRIBE Name:

DOCUMENT CONTROL NUMBER:

EMPLOYER ID NUMBER (EIN):

REPORT PERIOD:

GRANT AWARD YEAR:
ORIGINAL

From:

REPORTING ITEMS

To:

[

]

REVISED [

]

QUARTERLY [

]

FINAL

]

COLUMN (A)

COLUMN (B)

COLUMN (C)

COLUMN (D)

STATE CONTRIBUTED

TRIBAL FUNDS

American Recovery & Reinvestment Act

MOE FUNDS

ARRA FUNDS

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

EXPENDITURES ON ASSISTANCE

2a. Cash Assistance Payments (Basic Assistance)
2b. Other Assistance Expenditures
2c. TOTAL ASSISTANCE EXPENDITURES
EXPENDITURES ON NON-ASSISTANCE

3a. Administration
3b. Systems
3c. Other Non-Assistance Expenditures
3d. TOTAL NON-ASSISTANCE EXPENDITURES
TOTALS

4. Total Expenditures
5. Unliquidated Balance
6. Unobligated Balance

[

FEDERAL TFAG
FUNDS

1. TOTAL FEDERAL FUNDS AWARDED

SUBMISSION:

$

$

$

$

7. Tribal Replacement Funds

THIS IS TO CERTIFY THAT THE INFORMATION REPORTED ON ALL PARTS OF THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
SIGNATURE: TRIBAL OFFICIAL

TYPED NAME, TITLE

PHONE NUMBER:
DATE SUBMITTED:

CONTROL NO. 0970-0345

FORM ACF-196T PAGE 1 OF 1

EXPIRATION DATE: 07/31/2011

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