Form 1 Tanf Data Report 1

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

OMB Number 0979-0338 - Expiration Date 04/30/2011
ACF - 209

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

13.

17. Amount of Child Support

SSP MOE DATA REPORT - SECTION 1

Receives Food
Stamps

14.

Amount of Food Stamps
Assistance

18. Amount of the Family's Cash Resources

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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

21. Transportation
Number of Children
B.
Covered

A. Amount

Number of
C.
Months

A. Amount

22. Transitional Services

B. Number of Months

23. Other Assistance

A. Amount

B. Number of Months

A. Amount

B. Number of Months

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

Family Sanction for an
Adult with No High
iii.
School Diploma or
Equivalent

Sanction for
Teen Parent Not
iv.
Attending
School

v.

Non-cooperation
in Child Support

Failure to Comply with
vi. Individual Responsibility
Plan

vii.

.Reduction Based on Length of
Receipt of Assistance

iv.

Other Sanction

C. Other:
i.

Total Dollar Amount of Reductions Due to Other
Reasons (excludes Sanctions and Recoupment)

ii.

Family Cap

iii.

Other, Nonsanction

25. Waiver Evaluation Experimental and Control Group

OMB Number 0979-0338 - Expiration Date 04/30/2011
ACF - 209

SSP MOE DATA REPORT - SECTION 1

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PERSON LEVEL DATA

ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS

Adult

28. Date of Birth (Age)
Non-Custodial
26. Family Affiliation 27.
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

OMB Number 0979-0338 - Expiration Date 04/30/2011
ACF - 209

SSP MOE DATA REPORT - SECTION 1

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32. Receives Disability Benefits

Adult

31. Gender

Receives
Federal
A. Disability
Insurance
Benefits

B.

Receives
Benefits Based
on Federal
Disability Status

Receives Aid
C. Under Title XIVAPDT

Receives Aid
D. 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

OMB Number 0979-0338 - Expiration Date 04/30/2011
ACF - 209

SSP MOE DATA REPORT - SECTION 1

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ADULT WORK PARTICIPATION ACTIVITIES
Adult
Unsubsidized
43.
Employment

Subsidized
44.
Private Sector

Subsidized
45.
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

OMB Number 0979-0338 - Expiration Date 04/30/2011
ACF - 209

SSP MOE DATA REPORT - SECTION 1

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52.
Adult

A.

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 School Diploma or Certificate of High School Equivalency
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

55. Other Work Activities

C. Holidays

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 04/30/2011
ACF - 209

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

OMB Number 0979-0338 - Expiration Date 04/30/2011
ACF - 209

SSP MOE DATA REPORT - SECTION 1

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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 04/30/2011
ACF - 209

SSP MOE DATA REPORT - SECTION 1

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