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pdfTANF DATA REPORT - SECTION 1
TANF DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER
THE TANF PROGRAM
GENERAL INFORMATION
4.
1.
State FIPS Code
2.
County FIPS Code
3.
Tribal Code
(For Tribal Use Only)
Reporting Month
Year
Y
5.
Stratum
18.
Amount of Subsidized Child
Care
Month
Y
Y
Y
M
M
FAMILY LEVEL DATA
6.
Case Number - TANF
8.
Funding Stream
9.
Disposition
10.
New Applicant
7.
ZIP Code
11.
Number of Family Members
12.
Type of Family for Work
Participation
ASSISTANCE RECEIVED BY THE FAMILY
13.
Receives Subsidized
Housing
19.
Amount of Child Support
14.
Receives Medical
Assistance
20.
15.
Receives Food Stamps
16.
Amount of Food Stamps
Assistance
17.
Receives Subsidized
Child Care
Amount of the Family's Cash Resources
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering information to assess and evaluate whether a State
TANF program meets statutorily required participation rates. Public reporting burden for this collection of information is estimated to average 8,804 hours per grantee per year, including the time for reviewing
instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (42 U.S.C. § 611). An agency may not conduct or sponsor, and
a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is
0970-0338 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact the Office of Family Assistance by email at [email protected].
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
ACF - 199
TANF DATA REPORT - SECTION 1
Page 1
AMOUNT OF ASSISTANCE RECEIVED AND THE NUMBER OF MONTHS THAT THE FAMILY HAS RECEIVED
EACH TYPE OF ASSISTANCE UNDER STATE (TRIBAL) TANF PROGRAM
21.
Cash and Cash Equivalent
A.
Amount
22.
TANF Child Care
A.
Amount
24.
Transitional Services
A.
B.
Number of Months
23.
Number of Children
Covered
B.
C.
Number of Months
A.
25.
Amount
B.
. Transportation
Number of Months
Amount
B.
Number of Months
B.
Number of Months
Other Assistance
A.
Amount
REASON FOR AND AMOUNT OF REDUCTION IN ASSISTANCE
26.
27.
Reason and Amount of Reduction in Assistance
A.
Sanctions:
i.
Total Dollar Amount for
Reduction Due to
Sanctions
B.
Recoupment of Prior Overpayment
ii.
Waiver Evaluation Research Group
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
ACF - 199
Work Requirements
Sanction
28.
iii.
Family Sanction for an Adult with
No High School Diploma or
Equivalent
iv.
C.
Other
i.
Total Dollar Amount of Reduction Due to Other Reasons
Failure to Comply with an
Individual Responsibility
Plan
Sanction for Teen Parent
Not Attending School
v.
Non-cooperation
with Child Support
Family Cap
iii.
Reduction Based on Length of
Receipt of Assistance
ii.
Is the TANF Family Exempt from Federal Time Limit Provisions
TANF DATA REPORT - SECTION 1
29.
vi.
iv.
vii.
Other Sanction
Other, Non-sanction
Is the TANF Family a New Child-Only Family?
Page 2
PERSON LEVEL DATA
ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS
Adult
30. Family Affiliation
31.
Non-Custodial
Parent Indicator
32.
Date of Birth (Age)
Y
Y
Y
Y
33.
M
M
D
Social Security Number
D
1
-
-
2
-
-
3
-
-
4
-
-
5
-
-
6
-
-
34. Race/Ethnicity
Ethnicity
Adult
A.
Race
Hispanic or Latino
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
36.
Adult
35. Gender
A.
Receives Disability Benefits
Receives Federal Disability
Insurance Benefits - OASDI
B.
Receives Benefits Based on
Federal Disability Status
C.
Receives Aid Under Title
XIV-APDT
D.
Receives Aid Under Title
XVI-AABD
E.
Receives Aid Under Title
XVI-SSI
1
2
3
4
5
6
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TANF DATA REPORT - SECTION 1
Page 3
Adult
37. Marital Status
38.
Relationship to
Head of Household
44.
Number of Months
Countable Toward Federal
Time Limit
39.
Parent with Minor
Child in the Family
40.
Needs of a Pregnant
Woman
41.
Educational Level
47.
Employment Status
42.
Citizenship / Alienage
1
2
3
4
5
6
Adult
43.
Cooperation in Child
Support
45
Number of Countable Months
Remaining Under State's (Tribe's)
Time Limit
46.
Is Current Month Exempt
From State's (Tribe's) Time
Limit
48.
Work-Eligible
Individual Indicator
49.
Work Participation
54.
On-the-Job
Training
1
2
3
4
5
6
ADULT WORK PARTICIPATION ACTIVITIES
Adult
53.
50.
Unsubsidized
Employment
51.
Subsidized Private Sector
Employment
52.
Subsidized Public Sector
Employment
A.
Work Experience
Hours of
Participation
B.
Excused
Absences
C. Holidays
1
2
3
4
5
6
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TANF DATA REPORT - SECTION 1
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Adult
55. Job Search and Job Readiness Assistance
A.
Hours of
Participation
B.
Excused
Absences
56.
C. Holidays
Community Service Programs
A.
Hours of
Participation
B.
Excused
Absences
C. Holidays
1
2
3
4
5
6
Adult
57. Vocational Educational Training
A.
Hours of
Participation
B.
Excused
Absences
58.
C. Holidays
Job Skills Training Directly Related to Employment
A.
Hours of
Participation
B.
Excused
Absences
C. Holidays
1
2
3
4
5
6
Adult
59.
A.
Education Directly Related to Employment for Individuals with No High School
Diploma or Certificate of High School Equivalency
Hours of
Participation
B.
Excused
Absences
C. Holidays
60.
Satisfactory School Attendance for Individuals with No High School Diploma or
Certificate of High School Equivalency
A.
Hours of
Participation
B.
Excused
Absences
C. Holidays
1
2
3
4
5
6
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 1
Page 5
Adult
61.
A.
Providing Child Care Services to an Individual Who is Participating in a
Community Service Program
Hours of
Participation
B.
Excused
Absences
C. Holidays
62
Other Work Activities
63
Number of Deemed Core Hours for
Overall Rate
64
Number of Deemed Core Hours for the
Two-Parent Rate
1
2
3
4
5
6
AMOUNT OF INCOME, BY TYPE
66.
Adult
Amount of Unearned Income
65.
Amount of Earned Income
A.
Earned Income Tax Credit - EITC
B.
Social Security
C.
SSI
D.
Worker's Compensation
E.
Other Unearned Income
1
2
3
4
5
6
Adult
1
2
3
4
5
6
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TANF DATA REPORT - SECTION 1
Page 6
CHILD CHARACTERISTICS
Child
68.
67. Family Affiliation
Y
Date of Birth (Age)
Y
Y
Y
M
M
D
D
69.
Social Security Number
1
-
-
2
-
-
3
-
-
4
-
-
5
-
-
6
-
-
7
-
-
8
-
-
9
-
-
10
-
-
70. Race/Ethnicity
Ethnicity
Child
A.
Race
Hispanic or Latino
B.
American Indian or 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
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TANF DATA REPORT - SECTION 1
Page 7
Child
71. Gender
72.
Receives Disability Benefits:
A.
Receives Benefits Based on
Federal Disability Status
B.
Receives Aid Under
Title XVI-SSI
73.
Relationship to
Head of Household
74.
Parent with Minor
Child in the Family
75.
Educational Level
1
2
3
4
5
6
7
8
9
10
77.
Amount of Unearned Income
A.
SSI
Child
76. Citizenship / Alienage
B.
Other Unearned Income
1
2
3
4
5
6
7
8
9
10
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 1
Page 8
TANF DATA REPORT - SECTION 2
TANF DISAGGREGATED DATA COLLECTION FOR FAMILIES NO LONGER RECEIVING
ASSISTANCE UNDER THE TANF PROGRAM
GENERAL INFORMATION
1.
State FIPS Code
2
County FIPS Code
3.
Tribal Code
(For Tribal Use Only)
4.
Reporting Month
5
Year
Y
Stratum
Month
Y
Y
Y
M
Disposition
9.
M
FAMILY LEVEL DATA
6.
Case Number - TANF
7.
ZIP Code
8.
Reason for Closure
ASSISTANCE RECEIVED BY THE FAMILY
10.
Received Subsidized Housing
11.
Received Medical Assistance
12.
Received Food Stamps
13.
Received Subsidized Child Care
PERSON LEVEL DATA
Person
14.
Family Affiliation
15.
Y
Date of Birth (Age)
Y
Y
Y
16.
M
M
D
Social Security Number
D
1
-
-
2
-
-
3
-
-
4
-
-
5
-
-
6
-
-
7
-
-
8
-
-
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TANF DATA REPORT - SECTION 2
Page 9
Person
14.
Family Affiliation
15.
Y
Date of Birth (Age)
Y
Y
Y
16.
M
M
D
Social Security Number
D
9
-
-
10
-
-
11
-
-
12
-
-
13
-
-
14
-
-
15
-
-
16
-
-
17.
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: XX/XX/XXXX
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TANF DATA REPORT - SECTION 2
Page 10
Person
18.
Gender
19.
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 2
Page 11
Person
20.
Marital Status
26.
Number of Months Countable Toward
Federal Time Limit
21.
Relationship to Head of Household
22.
Parent with Minor
Child in Family
23.
Needs of a
Pregnant Woman
24.
Educational Level
25.
Citizenship /
Alienage
9
10
11
12
13
14
15
16
Person
27.
Number of Countable Months Remaining Under
State's (Tribe's) Time Limit
28.
Employment
Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 2
Page 12
AMOUNT OF INCOME, BY TYPE
Person
29.
Amount Earned Income
30.
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: XX/XX/XXXX
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TANF DATA REPORT - SECTION 2
Page 13
TANF DATA REPORT - SECTION 3
TANF AGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER
THE TANF PROGRAM
GENERAL INFORMATION
1.
State FIPS Code
2.
Tribal Code
(For Tribal Use Only)
3.
Calendar Quarter
Year
Y
Quarter
Y
Y
Y
Q
TANF APPLICATIONS
First Month
4.
Total Number of Applications
5.
Total Number of Approved Applications
6.
Total Number of Denied Applications
Second Month
Third Month
FAMILIES RECEIVING ASSISTANCE
First Month
7.
Second Month
Third Month
Total Amount of Assistance
$
$
8.
Total Number of Families
9.
Total Number of Two-Parent Families
10.
Total Number of One-Parent Families
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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$
TANF DATA REPORT - SECTION 3
Page 14
11.
Total Number of No-Parent Families
12.
Total Number of Recipients
13.
Total Number of Adult Recipients
14.
Total Number of Child Recipients
15.
Total Number of Non-Custodial Parents Participating in Work Activities
16.
Total Number of Births
17.
Total Number of Out-of-Wedlock Births
FAMILIES NO LONGER RECEIVING ASSISTANCE
First Month
18.
Second Month
Third Month
Total Number of Closed Cases
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 3
Page 15
TANF DATA REPORT - SECTION 4
NUMBER OF FAMILIES BY STRATUM FOR STATES THAT REPORT DATA BASED
ON A STRATIFIED SAMPLE
GENERAL INFORMATION
1.
State FIPS Code
2.
Tribal Code
(For Tribal Use Only)
3.
Calendar Quarter
Year
Y
Quarter
Y
Y
Y
Q
6. TOTAL NUMBER OF FAMILIES
4.
TDR Section Indicator
5.
Strarum
A. First Month
B. Second Month
C. Third Month
(1.)
(2)
(3.)
(4.)
(5.)
(6.)
(7.)
(8.)
(9.)
(10.)
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 4
Page 16
(11.)
(12.)
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 4
Page 17
SSP MOE DATA REPORT - SECTION 1
DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER THE
STATE SEPARATE PROGRAMS
GENERAL INFORMATION
3.
1.
State FIPS Code
2.
Reporting Month
County FIPS Code
Year
Y
Y
Y
Month
Y
M
4.
Stratum
M
FAMILY LEVEL DATA
5.
Case Number - Separate State MOE
6.
ZIP Code
7.
Disposition
8.
Number of
Family Members
9.
Type of Family for
Work Participation
ASSISTANCE RECEIVED BY THE FAMILY
Has the Family Received Assistance
10. Under a State (Tribal) TANF Program
Within the Past Six Months
15. Receives Subsidized Child Care
Has the Family Received
Assistance Under a State (Tribal)
11.
TANF Program Within the Past
Six Months
16. Amount of Subsidized Child Care
12.
Receives Medical
Assistance
17. Amount of Child Support
13.
Receives Food
Stamps
14.
Amount of Food Stamps
Assistance
18. Amount of the Family's Cash Resources
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering information to assess and evaluate whether
a Separate State Program – Maintenance of Effort (SSP-MOE) meets statutorily required participation rates. Public reporting burden for this collection of information is estimated to average 2,856
hours per grantee per year, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of
information (42 U.S.C. § 611). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction
Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0338 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information,
please contact the Office of Family Assistance by email at [email protected].
OMB Number 0979-0338 - Expiration Date: XX/XX/XXXX
ACF - 209
SSP MOE DATA REPORT - SECTION 1
Page 18
AMOUNT OF ASSISTANCE RECEIVED AND THE NUMBER OF MONTH THAT THE FAMILY HAS RECEIVED EACH TYPE OF ASSISTANCE UNDER
STATE SEPARATE PROGRAMS
19. Cash and Cash Equivalent
A.
Amount
B.
Number of Months
20. Child Care
A.
21. Transportation
Amount
B.
Number of Children
Covered
C.
Number of
Months
A.
22. Transitional Services
A.
Amount
B.
Number of Months
B.
Number of Months
23. Other Assistance
Amount
B.
Number of Months
A.
Amount
REASON FOR AND AMOUNT OF REDUCTION IN ASSISTANCE
24. Reason for and Amount of Reduction In Assistance:
A.: Sanctions:
i.
Total Dollar Amount of
Reduction Due to Sanctions
B.
Recoupment of Prior
Overpayment
ii.
Work
Requirements
Sanction
iii.
Family Sanction for an
Adult with No High
School Diploma or
Equivalent
Sanction for
Teen Parent Not
iv.
Attending
School
C.
Other:
i.
Total Dollar Amount of Reductions Due to Other
Reasons (excludes Sanctions and Recoupment)
ii.
v.
Non-cooperation
in Child Support
Family Cap
iii.
Failure to Comply with
vi. Individual Responsibility
Plan
vii.
.Reduction Based on Length of
Receipt of Assistance
iv.
Other Sanction
Other, Nonsanction
25. Waiver Evaluation Experimental and Control Group
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SSP MOE DATA REPORT - SECTION 1
Page 19
PERSON LEVEL DATA
ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS
28. Date of Birth (Age)
Adult
26. Family Affiliation
27.
Non-Custodial
Parent Indicator
Y
Y
Y
Y
M
M
D
D
29. Social Security Number
1
-
-
2
-
-
3
-
-
4
-
-
5
-
-
6
-
-
30. Race/Ethnicity
Ethnicity
Adult
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
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SSP MOE DATA REPORT - SECTION 1
Page 20
32. Receives Disability Benefits
Adult
31. Gender
A.
Receives
Federal
Disability
Insurance
Benefits
B.
Receives
Benefits Based
on Federal
Disability Status
C.
Receives Aid
Under Title XIVAPDT
D.
Receives Aid
Under Title XVIAABD
E.
Receives Aid Under
Title XVI-SSI
33. Marital Status
1
2
3
4
5
6
Adult
34.
Relation to Head of
Household
39.
Cooperation in
Child Support
35.
Parent with Minor
Child in Family
36.
Needs of a
Pregnant Woman
37. Educational Level
38.
Citizen-ship /
Alienage
1
2
3
4
5
6
Adult
40. Employment Status
41. Work-Eligible Individual Indicator
42. Work Participation Status
1
2
3
4
5
6
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SSP MOE DATA REPORT - SECTION 1
Page 21
ADULT WORK PARTICIPATION ACTIVITIES
Adult
43.
Unsubsidized
Employment
44.
Subsidized
Private Sector
45.
Subsidized
Public Sector
46. Work Experience
Hours of
A.
Participation
B.
Excused
Absences
C. Holidays
47.
On-the-Job
Training
1
2
3
4
5
6
Adult
48. Job Search and Job Readiness Assistance
Hours of
Excused
A.
B.
C. Holidays
Participation
Absences
49. Community Service Programs
Hours of
Excused
A.
B.
Participation
Absences
50. Vocational Educational Training
Hours of
Excused
A.
B.
Participation
Absences
51. Job Skills Training Directly Related to Employment
Hours of
Excused
A.
B.
C. Holidays
Participation
Absences
C. Holidays
1
2
3
4
5
6
Adult
C. Holidays
1
2
3
4
5
6
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SSP MOE DATA REPORT - SECTION 1
Page 22
Satisfactory School Attendance for Individuals with No
53. High School Diploma or Certificate of High School
Equivalency
Hours of
Excused
A.
B.
C. Holidays
Participation
Absences
Education Directly Related to Employment for Individuals with No High
52.
School Diploma or Certificate of High School Equivalency
Adult
A.
Hours of
Participation
B.
Excused
Absences
C. Holidays
1
2
3
4
5
6
54.
Adult
A.
Providing Child Care Services to an Individual Who is
Participating in a Community Service Program
Hours of
Participation
B.
Excused
Absences
C. Holidays
55. Other Work Activities
56.
Number of Deemed Core
Hours for Overall Rate
57.
Number of Deemed Core
Hours for Two-Parent Rate
1
2
3
4
5
6
AMOUNT OF INCOME, BY TYPE
59. Amount of Unearned Income
Adult
58.
Amount of
Earned Income
A.
Earned Income Tax
Credit-EITC
B.
Social Security
C.
SSI
D.
Worker's
Compensation
E.
Other Unearned
Income
1
2
3
4
5
6
OMB Number 0979-0338 - Expiration Date: XX/XX/XXXX
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SSP MOE DATA REPORT - SECTION 1
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CHILD CHARACTERISTICS
Child
61. Date of Birth (Age)
60. Family Affiliation
Y
Y
Y
Y
M
M
D
62. Social Security Number
D
1
-
-
2
-
-
3
-
-
4
-
-
5
-
-
6
-
-
7
-
-
8
-
-
9
-
-
10
-
-
63. Race/Ethnicity
Ethnicity
Child
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
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Child
64. Gender
65. Receives Disability Benefits:
Receives Benefits Based on
A.
Federal Disability Status
B.
Receives Aid Under
Title XVI-SSI
66.
Relationship to
Head of Household
67.
Parent with Minor
Child in the Family
68.
Educational
Level
1
2
3
4
5
6
7
8
9
10
70. Amount of Unearned Income
Child
69. Citizenship / Alienage
A.
SSI
B.
Other Unearned Income
1
2
3
4
5
6
7
8
9
10
OMB Number 0979-0338 - Expiration Date: XX/XX/XXXX
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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
-
-
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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
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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: XX/XX/XXXX
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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: XX/XX/XXXX
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SSP-MOE DATA REPORT - SECTION 2
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SSP-MOE DATA REPORT - SECTION 3
AGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER THE
STATE SEPARATE PROGRAM
GENERAL INFORMATION
1.
State FIPS Code
2.
Calendar Year and Quarter
Year
Y
Quarter
Y
Y
Y
Q
ACTIVE SSP CASES
First Month
3.
Total Number of SSP-MOE Families
4.
Total Number of Two-Parent Families
'5.
Total Number of One-Parent Families
6.
Total Number of No-Parent Families
7.
Total Number of Recipients
8.
Total Number of Adult Recipients
9.
Total Number of Child Recipients
10.
Total Number of Non-Custodial Parents Participating in Work Activities
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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Second Month
SSP-MOE DATA REPORT - SECTION 3
Third Month
Page 31
11.
Total Amount of Assistance
$
$
$
CLOSED SSP CASES
First Month
12.
Second Month
Third Month
Total Number of Closed Cases
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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SSP-MOE DATA REPORT - SECTION 3
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SSP-MOE DATA REPORT - SECTION 4
NUMBER OF FAMILIES BY STRATUM FOR STATES THAT REPORT DATA BASED
ON A STRATIFIED SAMPLE
GENERAL INFORMATION
1.
State Fips Code
2.
Calendar Year and Quarter
Year
Y
Quarter
Y
Y
Y
Q
5. TOTAL NUMBER OF FAMILIES
3.
SSP-MOE Data Report
Section Indicator
4. Stratum
A. First Month
B. Second Month
C. Third Month
1.
2.
3.
4.
5.
6.
7.
8.
9.
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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SSP-MOE DATA REPORT - SECTION 4
Page 33
10.
11.
12.
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
ACF - 209
SSP-MOE DATA REPORT - SECTION 4
Page 34
| File Type | application/pdf |
| Author | Anne Saulnier |
| File Modified | 2020-06-18 |
| File Created | 2020-06-15 |