Instructions for Annual Report on State Maintenance-of-Effort Programs: Form ACF-204

Forms and Documents

Document Name	Status
Form 204 Annual Report on State MOE Programs Form and Instruction	Modified
SUPSTAT_OFA ACF-204 - edit 10.5.15.doc Supporting Statement A	2015-10-06
PI-ACF-2041.pdf Supplementary Document	2014-12-22

IC Document Collections

IC ID	Document Title	Status
10099	Annual Report on State MOE Programs Form and Instruction	Modified

ICR Details

OMB Control No: 0970-0248	ICR Reference No: 201510-0970-002
Status: Historical Inactive	Previous ICR Reference No: 201412-0970-010
Agency/Subagency: HHS/ACF	Agency Tracking No:
Title: Instructions for Annual Report on State Maintenance-of-Effort Programs: Form ACF-204
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Preapproved	Conclusion Date: 10/08/2015
	Date Received in OIRA: 10/01/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2016	36 Months From Approved	10/31/2016
Responses	54	0	54
Time Burden (Hours)	7,452	0	6,372
Cost Burden (Dollars)	0	0	0

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Abstract: In accordance with P.L. 112-96, each state is required to report to the Secretary by February 22, 2014, and annually thereafter, on its implementation and maintenance of policies and practices that prevent TANF funded assistance from being used in any electronic benefit transfer transaction in any liquor store; any casino, gambling casino, or gaming establishment; or any retail establishment which provides adult-oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment. The Administration for Children and Families is required to reduce a state's block grant if the state fails to comply with this reporting requirement or if, based on the information that the state reports in their Annual TANF Report, ACF finds that the state has not implemented and maintained the required policies and practices.

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Authorizing Statute(s): US Code: 42 USC 611 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: PL: Pub.L. 112 - 96 4004 Name of Law: Middle Class Tax Relief and Job Creation Act of 2012

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0970-AC56	Proposed rulemaking	79 FR 7127	02/06/2014

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 44444	02/14/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 44444	10/01/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Annual Report on State MOE Programs	204	ACF-204

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	54	54	0	0	0	0
Annual Time Burden (Hours)	7,452	6,372	0	1,080	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden increase because of EBT requirement.

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Annual Cost to Federal Government: $35,100

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/01/2015

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