Annual Statistical Report on Children in Foster Homes and in Families Receiving Payments in Excess of the Poverty Income Level from a State Program

INSTRUCTIONS FOR FORM ACF-4125

ANNUAL STATISTICAL REPORT ON CHILDREN IN FOSTER HOMES
AND CHILDREN IN FAMILIES RECEIVING PAYMENTS IN EXCESS
OF THE POVERTY INCOME LEVEL FROM A STATE PROGRAM FUNDED
UNDER PART A OF TITLE IV OF THE SOCIAL SECURITY ACT

PURPOSE
The formula for computing grants for local education agencies to provide compensatory
education services for educationally deprived children, contained in Section 1124 of Title I of the
Elementary and Secondary Education Act, as amended by Public Law 107-110, includes October
caseload data for children in foster homes supported with public funds, and children in families
receiving annual payments in excess of the current poverty income level from a State program
funded under part A of Title IV of the Social Security Act (Block Grants to States for Temporary
Assistance for Needy Families (TANF)). The purpose of this annual survey is to provide these
data for each local educational agency (LEA) or county so that funds may be allocated on an
equitable basis. An electronic (MS Excel) version of this report is available on the Office of
Family Assistance’s Home Page: http://www.acf.hhs.gov/programs/ofa/datareports/ACF4125/FormACF.htm
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REQUIREMENT
This report is required annually of all State agencies administering or supervising administration
of TANF and child welfare programs, including the District of Columbia and Puerto Rico.
Guam, the Virgin Islands, and American Samoa are not required to report. No sampling or
estimating is to be used in preparing this report. Since the data reported will generate Federal
funds, they are subject to audit and must be supportable based on State TANF and foster care
records.
INSTRUCTIONS
Complete both Parts I and II. Data should be provided for each LEA or county in the lists
provided with this report form. If data are provided by LEA, it is not necessary to provide them
by county also.
For purposes of this form, a child who reaches the age of five years during October should be
included in the count. A child who attains 18 during October should not be counted.

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Part I.
Report, by LEA, the number of children aged 5-17 (inclusive) living in foster homes supported
by public funds during the month of October. If the data are not available by LEA, report by
county. Include foster homes of all types and under all programs, i.e., public agency foster
homes; group homes and foster homes where care is purchased by public agencies. "Public
funds" is defined as monies (Federal, State and/or local) which are used by public assistance
agencies to support foster children.
Children receiving foster care in institutions operated primarily for the care of neglected or
delinquent children should not be included in this report because a separate survey [U.S.
Department of Education ED FORM 4376] is conducted annually to collect the data on
neglected or delinquent institutionalized children.
Report only the children who reside within the State and report the children by LEA in which
they reside. If the LEA of residence is not known, the LEA of school attendance may be used. If
the LEA of residence changes during the month of October, the last known location should be
used.
Please assure that the sum of the data reported on attached pages is equal to the State total
shown on the form.
Part II.
Report, by LEA, the number of children aged 5-17 (inclusive) in families which, during the
month of October, received a cash assistance payment in excess of the amount specified for this
report period. If data are not available by LEA, report by county. (The "amount specified" is
based on poverty income guidelines for a family of four and will be provided annually to the
States by the Administration for Children and Families via Program Instruction or other
appropriate means.)
If no family received an assistance payment exceeding the amount specified, enter zero. Do not
include under this part children in foster care or those in institutions for neglected or delinquent
children. Include cash assistance only; non-monetary assistance and services, vendor payments
of all kinds, and income from any other sources should be excluded. Consider multiple cases in
the same dwelling as separate families.
Please assure that the sum of the data reported on attached pages is equal to the State total
shown on the form.
SUBMITTAL PROCEDURE
Please submit this report to the addresses given below. Also, please send a copy to the
appropriate HHS/ACF Regional Office.

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Please include on the front page the contact information (the name, telephone number and email
address) of the person who compiled the report.
If you have questions or need further information, please contact:
Paulette Bowen,
ACF/OFA/Division of Data Collection and Analysis:
Phone: 202/401-9251
FAX: 202/401-5554
FAX: 202/205-5887
E-mail: [email protected]
Mail: 370 L'Enfant Promenade, SW
ACF/OFA
5th Floor East
Washington, DC 20447
OR
Yun Song,
ACF/OFA/Division of Data Collection and Analysis:
Phone: 202/401-5293
FAX: 202/401-5554
FAX: 202/205-5887
E-mail: [email protected]
Mail: 370 L'Enfant Promenade, SW
ACF/OFA
5th Floor East
Washington, DC 20447
This report must be received in Washington, DC no later than December 31 following the report
period.
"PAPERWORK REDUCTION ACT OF 1995"
Public reporting burden for this collection of information is estimated to average 264 hours per
response, including the time for reviewing instructions, searching existing data sources, gathering
the data needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.

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