Form 1 OFA-100

Emergency Contingency Fund for Temporary Assistance for Needy Families (TANF) Programs

OFA-100 form

OFA-100

OMB: 0970-0366

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Form OFA-100 – TANF Emergency Fund Request Form

Part 1 – Request-Quarter Data

Jurisdiction: Date of Completion:

Request Year FY 2009

Which quarters have revised data? Q1 Q2 Q3 Q4
Category		Quarter 1 (Oct 2008-Dec 2008)	Quarter 2 (Jan 2009-Mar 2009)	Quarter 3 (Apr 2009-Jun 2009)	Quarter 4 (Jul 2009-Sep 2009)
Assistance Caseload
Expenditures	Basic Assistance
	Non-Recurrent Short-Term Benefits
	Subsidized Employment

Request Year FY 2010

Which quarters have revised data? Q1 Q2 Q3 Q4
Category		Quarter 1 (Oct 2009-Dec 2009)	Quarter 2 (Jan 2010-Mar 2010)	Quarter 3 (Apr 2010-Jun 2010)	Quarter 4 (Jul 2010-Sep 2010)
Assistance Caseload
Expenditures	Basic Assistance
	Non-Recurrent Short-Term Benefits
	Subsidized Employment

Administrative Expenditures

Expenditure category	Did you include administrative costs in this category?	Did you include them in the base-year quarters?
Basic assistance	yes no	yes no
Non-recurrent short-term benefits	yes no	yes no
Subsidized employment	yes no	yes no

Jurisdiction: Date of Completion: _

For each category in which you are requesting emergency funds, briefly describe the programs within the expenditure category. Then describe the reasons for the expenditure increase in the quarters for which you are requesting funding compared to the corresponding base quarters. If you are using estimated data, include the basis for the estimate.

Basic assistance expenditures consist of:

Basic assistance expenditure increases are due to:

The method for estimating any expenditures is:

Non-recurrent short-term benefit expenditures consist of:

Non-recurrent short-term benefit expenditure increases are due to:

The method for estimating any expenditures is:

Subsidized employment expenditures consist of:

Subsidized employment expenditure increases are due to:

The method for estimating any expenditures is:

Jurisdiction: Date of Completion: _
Section A – Program Configuration Changes
Answer each question in this section with each quarterly request for emergency funds.
Since October 1, 2006, has the jurisdiction made any changes in the groups of families receiving assistance in its TANF/SSP-MOE program that are the result of changes to a solely State-funded (SSF) program – either by starting or expanding a SSF, or by ending or scaling back a SSF? yes no If yes, have you completed Section B on a prior submission to account fully for these changes? yes no
Since October 1, 2006, has the jurisdiction converted any part of a program that provides non-assistance benefits (including non-recurrent short-term benefits) to a basic assistance program or converted any part of a basic assistance program to one that provides non-assistance benefits? yes no If yes, have you completed Section B on a prior submission to account for these changes? yes no
Since October 1, 2006, has the jurisdiction converted either a subsidized employment or a non-recurrent short term benefit program that operated outside of TANF/SSP-MOE to one that is within TANF? yes no If yes, have you completed Section B on a prior submission to account for these changes? yes no
Since October 1, 2006, are expenditures in any of your Emergency Fund categories subject to uneven claiming across quarters? For example, do you pay a contractor in a quarter to provide a service or benefit throughout the year but do not pay that contractor in the same quarter each year? yes no If yes, have you completed Section B on a prior submission to account for these changes? yes no
Since October 1, 2006, has the jurisdiction made any other changes that resulted in a change of funding between a TANF/SSP-MOE program and a SSF program or resulted in a funding change across any of the three categories? yes no If yes, have you completed Section B on a prior submission to account for these changes? yes no
Section B – Adjustments for Program Configuration Changes
Change # 1
Description of program change:
Date program change took effect:
Explanation of the methodology: Describe why the program change requires an adjustment and how you estimated the adjustment. Be sure to provide documentation to support the adjustments you are proposing to the assistance caseload and expenditure data.
Section B – Adjustments for Program Configuration Changes
Change # 2
Description of program change:
Date program change took effect:
Explanation of the methodology: Describe why the program change requires an adjustment and how you estimated the adjustment. Be sure to provide documentation to support the adjustments you are proposing to the assistance caseload and expenditure data.
Section B – Adjustments for Program Configuration Changes
Change # 3
Description of program change:
Date program change took effect:
Explanation of the methodology: Describe why the program change requires an adjustment and how you estimated the adjustment. Be sure to provide documentation to support the adjustments you are proposing to the assistance caseload and expenditure data.

Jurisdiction: Date of Completion: _

Section A – Program Configuration Changes

Answer each question in this section with each quarterly request for emergency funds.

Since October 1, 2006, has the jurisdiction made any changes in the groups of families receiving assistance in its TANF/SSP-MOE program that are the result of changes to a solely State-funded (SSF) program – either by starting or expanding a SSF, or by ending or scaling back a SSF?

yes no

If yes, have you completed Section B on a prior submission to account fully for these changes?

yes no

Since October 1, 2006, has the jurisdiction converted any part of a program that provides non-assistance benefits (including non-recurrent short-term benefits) to a basic assistance program or converted any part of a basic assistance program to one that provides non-assistance benefits?

yes no

If yes, have you completed Section B on a prior submission to account for these changes?

yes no

Since October 1, 2006, has the jurisdiction converted either a subsidized employment or a non-recurrent short term benefit program that operated outside of TANF/SSP-MOE to one that is within TANF?

yes no

If yes, have you completed Section B on a prior submission to account for these changes?

yes no

Since October 1, 2006, are expenditures in any of your Emergency Fund categories subject to uneven claiming across quarters? For example, do you pay a contractor in a quarter to provide a service or benefit throughout the year but do not pay that contractor in the same quarter each year?

yes no

If yes, have you completed Section B on a prior submission to account for these changes?

yes no

Since October 1, 2006, has the jurisdiction made any other changes that resulted in a change of funding between a TANF/SSP-MOE program and a SSF program or resulted in a funding change across any of the three categories?

yes no

If yes, have you completed Section B on a prior submission to account for these changes?

yes no

Section B – Adjustments for Program Configuration Changes

Change # 1

Description of program change:

Date program change took effect:

Explanation of the methodology:

Describe why the program change requires an adjustment and how you estimated the adjustment. Be sure to provide documentation to support the adjustments you are proposing to the assistance caseload and expenditure data.

Section B – Adjustments for Program Configuration Changes

Change # 2

Description of program change:

Date program change took effect:

Explanation of the methodology:

Section B – Adjustments for Program Configuration Changes

Change # 3

Description of program change:

Date program change took effect:

Explanation of the methodology:

Jurisdiction: Date of Completion: _

FY 2007 Base-Year Data

Which quarters have revised data? Q1 Q2 Q3 Q4
Average Monthly Assistance Caseload	Quarter 1 (Oct 2006-Dec 2006)	Quarter 2 (Jan 2007-Mar 2007)	Quarter 3 (Apr 2007-Jun 2007)	Quarter 4 (Jul 2007-Sep 2007)	FY 2007
Unadjusted Caseload
Total Adjustments
Adjusted Caseload	0	0	0	0	0

Which quarters have revised data? Q1 Q2 Q3 Q4
Basic Assistance Expenditures	Quarter 1 (Oct 2006-Dec 2006)	Quarter 2 (Jan 2007-Mar 2007)	Quarter 3 (Apr 2007-Jun 2007)	Quarter 4 (Jul 2007-Sep 2007)	FY 2007
Unadjusted Expenditures
Total Adjustments
Adjusted Expenditures	$0	$0	$0	$0

Which quarters have revised data? Q1 Q2 Q3 Q4
Non-Recurrent Short-Term Expenditures	Quarter 1 (Oct 2006-Dec 2006)	Quarter 2 (Jan 2007-Mar 2007)	Quarter 3 (Apr 2007-Jun 2007)	Quarter 4 (Jul 2007-Sep 2007)	FY 2007
Unadjusted Expenditures
Total Adjustments
Adjusted Expenditures	$0	$0	$0	$0	$0

Which quarters have revised data? Q1 Q2 Q3 Q4
Subsidized Employment Expenditures	Quarter 1 (Oct 2006-Dec 2006)	Quarter 2 (Jan 2007-Mar 2007)	Quarter 3 (Apr 2007-Jun 2007)	Quarter 4 (Jul 2007-Sep 2007)	FY 2007
Unadjusted Expenditures
Total Adjustments
Adjusted Expenditures	$0	$0	$0	$0	$0

Jurisdiction: Date of Completion: _

FY 2008 Base-Year Data

Which quarters have revised data? Q1 Q2 Q3 Q4
Average Monthly Assistance Caseload	Quarter 1 (Oct 2007-Dec 2007)	Quarter 2 (Jan 2008-Mar 2008)	Quarter 3 (Apr 2008-Jun 2008)	Quarter 4 (Jul 2008-Sep 2008)	FY 2008
Unadjusted Caseload
Total Adjustments
Adjusted Caseload	0	0	0	0	0

Which quarters have revised data? Q1 Q2 Q3 Q4
Basic Assistance Expenditures	Quarter 1 (Oct 2007-Dec 2007)	Quarter 2 (Jan 2008-Mar 2008)	Quarter 3 (Apr 2008-Jun 2008)	Quarter 4 (Jul 2008-Sep 2008)	FY 2008
Unadjusted Expenditures
Total Adjustments
Adjusted Expenditures	$0	$0	$0	$0

Which quarters have revised data? Q1 Q2 Q3 Q4
Non-Recurrent Short-Term Expenditures	Quarter 1 (Oct 2007-Dec 2007)	Quarter 2 (Jan 2008-Mar 2008)	Quarter 3 (Apr 2008-Jun 2008)	Quarter 4 (Jul 2008-Sep 2008)	FY 2008
Unadjusted Expenditures
Total Adjustments
Adjusted Expenditures	$0	$0	$0	$0	$0

Which quarters have revised data? Q1 Q2 Q3 Q4
Subsidized Employment Expenditures	Quarter 1 (Oct 2007-Dec 2007)	Quarter 2 (Jan 2008-Mar 2008)	Quarter 3 (Apr 2008-Jun 2008)	Quarter 4 (Jul 2008-Sep 2008)	FY 2008
Unadjusted Expenditures
Total Adjustments
Adjusted Expenditures	$0	$0	$0	$0	$0

Jurisdiction: Date of Completion _

You must complete a certification with each request for emergency funds.

Certification

I certify that:

(1) this request includes all expenditure and caseload data for the fiscal quarters for which we are requesting emergency funds and (if applicable) for the base years of FY 2007 and FY 2008;

(2) the data in this request are accurate;

(3) if the request includes estimated data, the estimates are reasonable; and

(4) the request includes adjustments for all program configuration changes that would affect quarterly comparisons of the base-year and request-quarter data.

___________________________________________________________

(signature)

(name)

(title)

Contact in the Jurisdiction

In the event that we have questions about any of the information in this request for emergency funds, please provide a contact with whom we can discuss them.

Name:

Telephone:

Email:

OMB Control No.: 0970-0366 Expiration Date: 12/31/2009

Page 1 of 10

File Type	application/msword
File Title	OFA-100 form -approved- edits 10-2009
Author	ACF
Last Modified By	Holly Higgins
File Modified	2009-10-29
File Created	2009-10-29

Form 1 OFA-100

Emergency Contingency Fund for Temporary Assistance for Needy Families (TANF) Programs

OFA-100 form

OFA-100

OMB: 0970-0366

Jurisdiction:   Date of Completion:  

Request Year FY 2009

Jurisdiction: Date of Completion: _

Section A – Program Configuration Changes

Jurisdiction: Date of Completion: _

Jurisdiction: Date of Completion: _

Jurisdiction: Date of Completion _

Certification

Jurisdiction: Date of Completion: