Form 2 TANF Data Report 2

SSP-MOE DATA REPORT - SECTION 2
DISAGGREGATED DATA COLLECTION FOR FAMILIES NO LONGER RECEIVING
ASSISTANCE UNDER THE STATE SEPARATE PROGRAM
GENERAL INFORMATION

1.

State FIPS Code

2.

County FIPS Code

3.

Reporting Month
Year

Y

4.

Stratum

7.

Disposition

Month

Y

Y

Y

M

M

FAMILY LEVEL DATA

5.

Case Number - State Separate Program

6.

Zip Code

8.

Reason for Closure

ASSISTANCE RECEIVED BY THE FAMILY

9.

Received Subsidized Housing

10.

Received Medical Assistance

11.

Received Food Stamps

12.

Received Subsidized Child Care

PERSON LEVEL DATA

Person

13.

Family Affiliation

14.
Y

Date of Birth (Age)
Y

Y

Y

15.
M

M

D

Social Security Number

D

1

-

-

2

-

-

3

-

-

4

-

-

5

-

-

6

-

-

7

-

-

8

-

-

OMB Number 0970-0338 - Expiration Date 04/30/2011
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SSP-MOE DATA REPORT - SECTION 2

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Person

13.

Family Affiliation

14.

Date of Birth (Age)

15.

Social Security Number

9

-

-

10

-

-

11

-

-

12

-

-

13

-

-

14

-

-

15

-

-

16

-

-

16.

Race/Ethnicity

Ethnicity
Person

A.

Hispanic or Latino

Race
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
11
12
13
14
15
16

OMB Number 0970-0338 - Expiration Date 04/30/2011
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SSP-MOE DATA REPORT - SECTION 2

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Person

17.

Gender

20.

Relationship to
Head of Household

18.

Received Disability Benefits

A.

Received Federal Disability
Insurance Benefits - OASDI

B.

Received Benefits Based
on Federal Disability Status

C.

Received Aid Under Title
XIV-APDT

D.

Received Aid Under
Title XVI-AABD

E.

Received Aid Under Title
XVI-SSI

19.

Marital Status

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

Person

21.

Parent with Minor
Child in the Family

22.

Needs of a
Pregnant Woman

23.

Educational
Level

24.

Citizenship /
Alienage

25.

Employment
Status

1
2
3
4
5
6
7
8

OMB Number 0970-0338 - Expiration Date 04/30/2011
ACF - 209

SSP-MOE DATA REPORT - SECTION 2

Page 3

Person

20.

Relationship to
Head of Household

21.

Parent with Minor
Child in the Family

22.

Needs of a
Pregnant Woman

23.

Educational
Level

24.

Citizenship /
Alienage

25.

Employment
Status

9
10
11
12
13
14
15
16

AMOUNT OF INCOME, BY TYPE

Person

26.

Amount of Earned Income

27.

Amount of Unearned Income

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

OMB Number 0970-0338 - Expiration Date 04/30/2011
ACF - 209

SSP-MOE DATA REPORT - SECTION 2

Page 4