Form 196R Quarterly Financial Report

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Overview

ACF-196R Part 1
ACF-196R Part 2

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Sheet 1: ACF-196R Part 1

Department of Health and Human Services
Administration for Children and Families
Temporary Assistance for Needy Families (TANF) ACF - 196R Financial Report Part 1: Expenditure Data
State	Grant Year	Fiscal Year	Report Quarter Ending	Next Quarter Ending	Report is Submitted as: [ ] New [ ] Revised -------------------------------- [ ] Final (Zero Grant Funds Remaining)
	Federal Funds	State Funds		Federal Funds	Federal Funds
	State Family Assistance Grant			Contingency Funds Award Reconciliation Federal Share at FMAP Rate of: ______%	Emergency Contingency Funds (Authorized by ARRA)
	(A)	(B)	(C)	(D)	(E)
1. Awarded				$
2. Transferred to CCDF Discretionary	$
3. Transferred to SSBG	$
4. Adjusted Award
5. Carryover
Expenditures Categories	FEDERAL EXPENDITURES	STATE MOE EXPENDITURES IN TANF	MOE EXPENDITURES SEPARATE STATE PROGRAMS	EXPENDITURES WITH CONTINGENCY FUNDS	EXPENDITURES WITH EMERGENCY CONTINGENCY FUNDS
6 Basic Assistance
6.a. Basic Assistance (excluding Relative Foster Care Maintenance Payments and Adoption and Guardianship Subsidies)	$	$	$	$	$
6.b. Relative Foster Care Maintenance Payments and Adoption and Guardianship Subsidies	$	$	$	$	$
7. Assistance Authorized Solely Under Prior Law
7.a. Foster Care Payments	$			$	$
7.b. Juvenile Justice Payments	$			$	$
7.c. EmergencyAssistance Authorized Solely Under Prior Law	$			$	$
8. Non-Assistance Authorized Solely Under Prior Law
8.a. Child Welfare or Foster Care Services	$			$	$
8.b. Juvenile Justice Services	$			$	$
8.c. Emergency Services Authorized Solely Under Prior Law	$			$	$
9. Work, Education, and Training Activities
9.a. Subsidized Employment	$	$	$	$	$
9.b. Education and Training	$	$	$	$	$
9.c. Additional Work Activities	$	$	$	$	$
10. Work Supports
11. Early Care and Education
11.a. Child Care (Assistance and Non-Assistance)	$	$	$	$	$
11.b. Pre-Kindergarten/Head Start	$	$	$	$	$
12. Financial Education and Asset Development	$	$	$	$	$
13. Refundable Earned Income Tax Credits	$	$	$	$	$
14. Non-EITC Refundable State Tax Credits	$	$	$	$	$
15. Non-Recurrent Short Term Benefits	$	$	$	$	$
16. Supportive Services	$	$	$	$	$
17. Services for Children and Youth	$	$	$	$	$
18. Prevention of Out-of-Wedlock Pregnancies	$	$	$	$	$
19. Fatherhood and Two-Parent Family Formation and Maintenance Programs	$	$	$	$	$
20. Child Welfare Services
20.a. Family Support/ Family Preservation /Reunification Services	$	$	$	$	$
20.b. Adoption Services	$	$	$	$	$
20.c. Additional Child Welfare Services	$	$	$	$	$
21. Home Visiting Programs	$	$	$	$	$
22. Program Management
22.a. Administrative Costs	$	$	$	$	$
22.b. Assessment/Service Provision	$	$	$	$	$
22.c. Systems	$	$	$	$	$
23.Other	$	$	$	$	$
24.Total Expenditures
25 Transitional Services for Employed	$	$	$	$	$
26 Job Access	$	$	$
27. Federal Unliquidated Obligations	$			$	$
28. Unobligated Balance	$			$	$
29. State Replacement Funds		$
Quarterly Estimate	Estimate TANF Federal Funds
30. Estimate of TANF Funds Requested for the Following Quarter	$
THIS IS TO CERTIFY THAT THE INFORMATION REPORTED ON ALL PARTS OF THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
SIGNATURE: AUTHORIZED STATE OFFICIAL			TYPED NAME, TITLE, AGENCY NAME
DATE SUBMITTED:
PAGE 1 OF 2 of APPROVED OMB No: 0970-XXXX, Expiration Date XX/XX/XXXX

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Sheet 2: ACF-196R Part 2

Department of Health and Human Services
Administration for Children and Families
Temporary Assistance for Needy Families (TANF) ACF - 196R Financial Report Part 2: Narrative Section
	State	Fiscal Year
Expenditure Categories	Descriptions of Expenditures		Methodology Used to Estimate Federal Funding and State MOE Expenditures
6 Basic Assistance
6.a. Basic Assistance (excluding Relative Foster Care Maintenance Payments and Adoption and Guardianship Subsidies)
6.b. Relative Foster Care Maintenance Payments and Adoption and Guardianship Subsidies
7. Assistance Authorized Solely Under Prior Law
7.a. Foster Care Payments
7.b. Juvenile Justice Payments
7.c. EmergencyAssistance Authorized Solely Under Prior Law
8. Non-Assistance Authorized Solely Under Prior Law
8.a. Child Welfare or Foster Care Services
8.b. Juvenile Justice Services
8.c. Emergency Services Authorized Solely Under Prior Law
9. Work, Education, and Training Activities
9.a. Subsidized Employment
9.b. Education and Training
9.c. Additional Work Activities
10. Work Supports
11. Early Care and Education
11.a. Child Care (Assistance and Non-Assistance)
11.b. Pre-Kindergarten/Head Start
12. Financial Education and Asset Development
13. Refundable Earned Income Tax Credits
14. Non-EITC Refundable State Tax Credits
15. Non-Recurrent Short Term Benefits
16. Supportive Services
17. Services for Children and Youth
18. Prevention of Out-of-Wedlock Pregnancies
19. Fatherhood and Two-Parent Family Formation and Maintenance Programs
20. Child Welfare Services
20.a. Family Support/ Family Preservation /Reunification Services
20.b. Adoption Services
20.c. Additional Child Welfare Services
21. Home Visiting Programs
22. Program Management
22.a. Administrative Costs
22.b. Assessment/Service Provision
22.c. Systems
23.Other
THIS IS TO CERTIFY THAT THE INFORMATION REPORTED ON ALL PARTS OF THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
SIGNATURE: AUTHORIZED STATE OFFICIAL			TYPED NAME, TITLE, AGENCY NAME
DATE SUBMITTED:
PAGE 2 OF 2 of APPROVED OMB No: 0970-XXXX, Expiration Date XX/XX/XXXX