Form ACF 4125 ACF 4125 Annual Report on Children in Foster Homes and in Familie

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Overview

Cover
County
LEA

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Sheet 1: Cover

DEPARTMENT OF HEALTH AND HUMAN SERVICES	OMB Approval No.: 0970-0004
Administration for Children and Families	Expires: XX/XX/XXXX
Form ACF-4125	DESTROY PRIOR EDITIONS
ANNUAL REPORT ON
CHILDREN IN FOSTER HOMES AND CHILDREN IN FAMILIES RECEIVING PAYMENTS
IN EXCESS OF THE POVERTY INCOME LEVEL
FROM A STATE PROGRAM FUNDED UNDER PART A OF
TITLE IV OF THE SOCIAL SECURITY ACT
State __________________________________	State Agency ___________________________
Report for the month of October XXXX
Prepared by:
Name __________________________________________________
Title ___________________________________________________
Signature_______________________________________________
Compiled by:
Name __________________________________________________
Phone # ________________________________________________
Email address____________________________________________
Part I.
NUMBER OF CHILDREN AGED 5-17 IN FOSTER HOMES
State total _______________
(if entry is greater than zero (0), attach a separate list in the following format.)
Children Aged 5-17 in Foster Homes
A. by COUNTY	B. by LOCAL EDUCATIONAL AGENCY (LEA)
County name FIPS County Code Number	LEA name LEA Code (Agency ID) Number
Part II.
NUMBER OF CHILDREN AGED 5-17 IN FAMILIES RECEIVING PAYMENTS IN EXCESS OF
THE AMOUNT SPECIFIED FOR THIS REPORT PERIOD FROM A STATE PROGRAM FUNDED UNDER
PART A OF TITLE IV OF THE SOCIAL SECURITY ACT
State total _______________
(if entry is greater than zero (0), attach a separate list in the following format.)
Children Aged 5-17 in FAMILIES RECEIVING PAYMENTS IN EXCESS OF $XXXX
A. by COUNTY	B. by LOCAL EDUCATIONAL AGENCY (LEA)
County name FIPS County Code Number	LEA name LEA Code Number
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Public reporting burden for this collection of information is estimated to average 264 hours per response, 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 (Pub L. 107-110 Sec: 1124(c)(4). Pub L. 104-193 Sec: 110(j))]. 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 0970-0004 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact [email protected].

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Sheet 2: County

Number of children ages 5 - 17 (inclusive) in foster homes and in families receiving payments under TANF in excess of poverty level
NAME OF STATE:
				OFA: XXXX=reporting year YYYY=year prior to reporting year October XXXX	October YYYY	October XXXX	October YYYY
			Name of	Number of	Number of	Number of Children Ages 5-17	Number of Children Ages 5-17
			Local Educational	Children Ages 5-17	Children Ages 5-17	in Families Receiving Payments	in Families Receiving Payments
State	State Code	County Code	Agency (LEA)	In Foster Homes	In Foster Homes	Under TANF in Excess of Poverty Level	Under TANF in Excess of Poverty Level
			STATE TOTAL	0	0	0	0

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Sheet 3: LEA

Number of children ages 5 - 17 (inclusive) in foster homes and in families receiving payments under TANF in excess of poverty level
NAME OF STATE:
				OFA: XXXX=reporting year YYYY=year prior to reporting year October XXXX	October YYYY	October XXXX	October YYYY
				Number of	Number of	Number of Children Ages 5-17	Number of Children Ages 5-17
			Name of	Children Ages 5-17	Children Ages 5-17	in Families Receiving Payments	in Families Receiving Payments
State	State Code	LEA Code	Local Educational Agency (LEA)	In Foster Homes	In Foster Homes	Under TANF in Excess of Poverty Level	Under TANF in Excess of Poverty Level
			STATE TOTAL	0	0	0	0