ACF-700 Reporting Form

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CHILD CARE AND DEVELOPMENT FUND ANNUAL REPORT
ON SERVICES PROVIDED FROM OCTOBER 1, 20__ THROUGH SEPTEMBER 30, 20__

OMB Control Number: 0980-0241
Expiration Date: 2/28/2011

CATEGORY/TYPE OF CHILD CARE
CARE PROVIDED BY
A CCDF PROVIDER--NO LICENSE CATEGORY AVAILABLE
IN A

COMPLETE NAME OF TRIBAL LEAD AGENCY:
ADDRESS:

CONTACT PERSON:

CARE PROVIDED BY CCDF PROVIDER-LICENSED OR REGULATED
IN A

CHILD'S HOME BY A

FAMILY HOME BY A

(A)

(B)

(C)

(D)

(E)

GROUP HOME BY A
(F)

(G)

(H)

(I)

(J)

(K)

(L)

TOTAL

Relative

Non-Relative

Relative

Non-Relative

Relative

Non-Relative

Center

Child's Home

Family Home

Group Home

Center

Phone:
E-Mail:
1. Total number of families that received child care services this fiscal year
2 a. Average number of children served each month
2 b. Total number of children that received services this fiscal year
3. Total number of children receiving services that fall
into each age category:
a. 0 up to 1 year
b. 1 year up to 2 years
c. 2 years up to 3 years
d. 3 years up to 4 years
e. 4 years up to 5 years
f. 5 years up to 6 years
g. 6 years up to 13 years
h. Total number of children 0 to 13 years (add Column A, 3a thru 3g)
i. 13 years and older
4. Number of children who received child care services
Because:
a. Their parent(s) worked
b. Their parent(s) were in training or an education program
c. Child received or needed protective services
Because there was a Federal Emergency and:
d. Their parent(s) worked
e. Their parent(s) were in training or an education program
f. Child received or needed protective services
5. Average number of hours of child care service provided
per child per month

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

c.

c.

c.

c.

c.

c.

c.

c.

c.

c.

c.

c.

d.
e.
f.
g.
h.

d.
e.
f.
g.
h.

d.
e.
f.
g.
0 h.

d.
e.
f.
g.
0 h.

d.
e.
f.
g.
0 h.

d.
e.
f.
g.
0 h.

d,
e.
f.
g.
0 h.

d.
e.
f.
g.
0 h.

d.
e.
f.
g.
0 h.

d.
e.
f.
g.
0 h.

d.
e.
f.
g.
0 h.

d.
e.
f.
g.
0 h.

i.

i.

i.

i.

i.

i.

i.

i.

i.

i.

i.

i.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.

a.
b.
c.
d.

a.
b.
c.
d.

a.
b.
c.
d.

a.
b.
c.
d.

a.
b.
c.
d.

a.
b.
c.
d.

a.
b.
c.
d.

a.
b.
c.
d.

a.
b.
c.
d.

a.
b.
c.
d.

a.
b.
c.
d.
e.
f.

6. Average monthly amount paid for child care service
a. Average monthly CCDF program subsidy per child
b. Average monthly parent copayment per child
7. Number of children served whose family income was:
a. at or below the poverty threshold for families of the same size

a.
b.
a.

]

b. above the poverty threshold but at or below 150 percent of the poverty
b.
threshold for families of the same size
c. above 150 percent of the poverty threshold but at or below 200 percent of
c.
the poverty threshold for families of the same size
d. above 200 percent of the poverty threshold for families of the same size
d.
8. Number of children served by payment type this fiscal year:
a. Grant/contract with provider
b. Certificate or voucher to parent and/or provider
c. Cash payment to parent
d. Tribally-operated center
Comments: (Please use the back of this sheet if necessary)

a.
b.
c.
d.

a.
b.
c.
d.

Public reporting burden for this collection of information is estimated to average 38 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.
ACF 700

0