Form 1 MOE Report 1

DRA TANF Final Rule

sspmoerpt1.xls

SSP-MOE Data Report

OMB: 0970-0338

Document [xlsx]
Download: xlsx | pdf

Overview

SSP-MOE Section 1 Page1
SSP-MOE Section 1 page 2
SSP-MOE Section 1 page 3
SSP-MOE Section 1 page 4
SSP-MOE Section 1 page 5
SSP-MOE Section 1 page 6
SSP-MOE Section 1 page 7
SSP-MOE Section 1 page 8
SSP-MOE Section 1 page 9
SSP-MOE Section 1 page 10


Sheet 1: SSP-MOE Section 1 Page1

SSP MOE DATA REPORT - SECTION 1
DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER THE
STATE SEPARATE PROGRAMS






































































GENERAL INFORMATION
















































3. Reporting Month











1. State FIPS Code 2. County FIPS Code



Year
Month

4. Stratum






















































Y Y Y Y
M M
















































FAMILY LEVEL DATA






































5. Case Number - Separate State MOE
6. ZIP Code 7. Disposition 8. Number of Family Members 9. Type of Family for
Work Participation







































































ASSISTANCE RECEIVED BY THE FAMILY






































10. Has the Family Received Assistance Under a State (Tribal) TANF Program Within the Past Six Months 11. Has the Family Received Assistance Under a State (Tribal) TANF Program Within the Past Six Months 12. Receives Medical Assistance 13. Receives Food Stamps 14. Amount of Food Stamps Assistance









































































15. Receives Subsidized Child Care 16. Amount of Subsidized Child Care 17. Amount of Child Support 18. Amount of the Family's Cash Resources








































































Sheet 2: SSP-MOE Section 1 page 2







































































AMOUNT OF ASSISTANCE RECEIVED AND THE NUMBER OF MONTHW THAT THE FAMILY HAS RECEIVED EACH TYPE OF ASSISTANCE UNDER STATE SEPARATE PROGRAMS


19. Cash and Cash Equivalent



















A. Amount


B. Number of Months



























































































20. Child Care


21. Transportation


A. Amount
B. Number of Children Covered C. Number of Months



A. Amount

B. Number of Months









































































22. Transitional Services



23. Other Assistance


A. Amount


B. 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:






















i. Total Dollar Amount of Reduction Due to Sanctions ii. Work Requirements Sanction iii. Family Sanction for an Adult with No High School Diploma or Equivalent iv. Sanction for Teen Parent Not Attending School v. Non-cooperation in Child Support vi. Failure to Comply with Individual Responsibility Plan vii. Other Sanction




































Sheet 3: SSP-MOE Section 1 page 3









C. Other:
















B. Recoupment of
Prior Overpayment
i. Total Dollar Amount of Reductions Due to Other Reasons (excludes Sanctions and Recoupment) ii. Family Cap iii. .Reduction Based on Length of Receipt of Assistance iv. Other, Non-sanction






































































25. Waiver Evaluation Experimental and Control Group

































































































































PERSON LEVEL DATA



































ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS



































Adult











28. Date of Birth (Age)














26. Family Affiliation 27. Non-Custodial Parent Indicator Y Y Y Y M M D D
29. Social Security Number


1























-

-





2























-

-





3























-

-





4























-

-





5























-

-





6























-

-





Sheet 4: SSP-MOE Section 1 page 4




30. Race/Ethnicity



















Ethnicity
Race












Adult
A. Hiispanic 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

































































32. Receives Disability Benefits















Adult
31. Gender A. Receives Federal Disability Insurance Benefits B. Receives Benefits Based on Federal Disability Status C. Receives Aid Under Title XIV-APDT D. Receives Aid Under Title XVI-AABD E. Receives Aid Under Title XVI-SSI 33. Marital Status

1





























2





























3





























4





























5





























6





























Sheet 5: SSP-MOE Section 1 page 5

Adult 34. Relation to Head of Household 35. Parent with Minor
Child in Family
36. Needs of a
Pregnant Woman
37. Educational Level 38. Citizen-ship / Alienage







1

































2

































3

































4

































5

































6



































































Adult
39. Cooperation in
Child Support
40. Employment Status 41. Work-Eligible Individual Indicator 42. Work Participation Status








1

































2

































3

































4

































5

































6




































































Sheet 6: SSP-MOE Section 1 page 6

ADULT WORK PARTICIPATION ACTIVITIES



































Adult















46. Work Experience








43. Unsubsidized
Employment
44. Subsidized
Private Sector
45. Subsidized
Public Sector
A. Hours of Participation B. Excused Absences
C. Holidays

47. On-the-Job
Training

1

































2

































3

































4

































5

































6



































































Adult
48. Job Search and Job Readiness Assistance






49. Community Service Programs





A. Hours of Participation B. Excused Absences
C. Holidays






A. Hours of Participation B. Excused Absences
C. Holidays



1

































2

































3

































4

































5

































6




































































Sheet 7: SSP-MOE Section 1 page 7



50. Vocational Educational Training






51. Job Skills Training Directly Related to Employment



A. Hours of Participation B. Excused Absences
C. Holidays






A. Hours of Participation B. Excused Absences
C. Holidays

1






























2






























3






























4






























5






























6































































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




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



A. Hours of Participation B. Excused Absences
C. Holidays






A. Hours of Participation B. Excused Absences
C. Holidays

1






























2






























3






























4






























5






























6






























































Sheet 8: SSP-MOE Section 1 page 8





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


















Adult


A. Hours of Participation B. Excused Absences
C. Holidays

55. Other Work Activities 56. Number of Deemed Core Hours for Overall Rate 57. Number of Deemed Core Hours for Two-Parent Rate

1
1































2
2































3
3































4
4































5
5































6
6

































































AMOUNT OF INCOME, BY TYPE











































59. Amount of Unearned Income



















Adult
58. Amount of Earned Income
A. Earned Income Tax Credit-EITC B. Social Security C. SSI
D. Worker's Compensation E. Other Unearned Income



1

































2

































3

































4

































5

































6




































































Sheet 9: SSP-MOE Section 1 page 9

CHILD CHARACTERISTICS
Child






61. Date of Birth (Age)















60. Family Affiliation
Y Y Y Y M M D D
62. Social Security Number

1



















-

-





2



















-

-





3



















-

-





4



















-

-





5



















-

-





6



















-

-





7



















-

-





8



















-

-





9



















-

-





10



















-

-






































63. Race/Ethnicity























Ethnicity
Race
















Child A. .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





























Sheet 10: SSP-MOE Section 1 page 10








65. Receives Disability Benefits:















Child 64. Gender A. Receives Benefits Based on Federal Disability Status B. Receives Aid Under
Title XVI-SSI
66. Relationship to Head of Household 67. Parent with Minor Child in the Family 68. Educational Level

1

































2

































3

































4

































5

































6

































7

































8

































9

































10












































































70. Amount of Unearned Income













Child 69. Citizenship / Alienage A. SSI



B. Other Unearned Income














1

































2

































3

































4

































5

































6

































7

































8

































9

































10



































































File Typeapplication/vnd.ms-excel
AuthorAnne Saulnier
Last Modified ByACF
File Modified2007-11-07
File Created2006-06-07

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