Final Tribal TANF Data Report

TRIBAL TANF DATA REPORT - SECTION 1

TANF DISAGGREGATED DATA COLLECTION FOR FAMILIES 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. Stratum
																		Year					Month
																		Y	Y	Y	Y		M	M

FAMILY LEVEL DATA

6. Case Number - TANF

7. ZIP Code

8. Funding Stream

9. Disposition

10. New Applicant

11. Number of Family Members

12. Type of Family for Work Participation

ASSISTANCE RECEIVED BY THE FAMILY

13. Receives Subsidized Housing

14. Receives Medical Assistance

15. Receives Food Stamps

16. Amount of Food Stamps Assistance

17. Receives Subsidized Child Care

18. Amount of Subsidized Child Care

19. Amount of Child Support

20. Amount of the Family's Cash Resources

ASSISTANCE PROVIDED UNDER STATE (TRIBAL) TANF PROGRAM, BY TYPE

21. Cash and Cash Equivalent

A. Amount

B. Number of Months

22. TANF Child Care

23. Transportation

A. Amount

B. Number of Children Covered

C. Number of Months

A. Amount

B. Number of Months

24. Transitional Services

25. Other Assistance

A. Amount

B. Number of Months

A. Amount

B. Number of Months

REASON FOR AND AMOUNT OF REDUCTION IN ASSISTANCE

26. Reason for and Amount of Reduction In Assistance:

A. Sanctions:

i. Total Dollar Amount for Reduction Due to Sanctions

ii. Work Requirements Sanction

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

iv. Sanction for Teen Parent Not Attending School

v. Non-cooperation with Child Support

vi. Failure to Comply with an Individual Responsibility Plan

vii. Other Sanction

B. Recoupment of Prior Overpayment

C. Other:

i. Total Dollar Amount of Reduction Due to Other Reasons

ii. Family Cap

iii. Reduction Based on Length of Receipt of Assistance

iv. Other, Non-sanction

27. Waiver Evaluation Research Group

28. Is the TANF Family Exempt from Federal Time Limit Provisions

29. Is the TANF Family a New Child-Only Family?

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)									33. Social Security Number
											Y	Y	Y	Y	M	M	D	D
	1																						-			-
	2																						-			-
	3																						-			-
	4																						-			-
	5																						-			-
	6																						-			-

34. Race/Ethnicity

Ethnicity

Race

Adult

A. 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. Receives Disability Benefits
Adult			35. Gender				A. 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

Adult

37. Marital Status

38. Relationship to Head of Household

39. Parent with Minor Child in the Family

40. Needs of a Pregnant Woman

41. Educational Level

42. Citizenship / Alienage

1

Adult			37. Marital Status				38. Relationship to Head of Household					39. Parent with Minor Child in the Family				40. Needs of a Pregnant Woman				41. Educational Level					42. Citizenship / Alienage
	2
	3
	4
	5
	6

Adult			43. Cooperation in Child Support					44. Number of Months Countable Toward Federal Time Limit					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					47. Employment Status				48. Work Participation Status
	1
	2
	3
	4
	5
	6

ADULT WORK PARTICIPATION ACTIVITIES

Adult			49. Unsubsidized Employment					50. Subsidized Private Sector Employment					51. Subsidized Public Sector Employment					52. Work Experience					53. On-the-Job Training
	1
	2
	3
	4

Adult

49. Unsubsidized Employment

50. Subsidized Private Sector Employment

51. Subsidized Public Sector Employment

52. Work Experience

53. On-the-Job Training

5

6

Adult			54. Job Search and Job Readiness Assistance					55. Community Service Programs					56. Vocational Educational Training					57. Job Skills Training Directly Related to Employment					58. Education Directly Related to Employment for Individuals with No High School Diploma or Certificate of High School Equivalency
	1
	2
	3
	4
	5
	6

Adult			59. Satisfactory School Attendance for Individuals with No High School Diploma or Certificate of High School Equivalency						60. Providing Child Care Services to an Individual Who is Participating in a Community Service Program						61. Additional Work Activities Permitted Under Waiver Demonstration						62. Other Work Activities					63. Required Hours of Work Under Waiver Demonstration
	1
	2
	3
	4
	5
	6

AMOUNT OF INCOME, BY TYPE

							65. Amount of Unearned Income
Adult		64. 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

CHILD CHARACTERISTICS

Child			66. Family Affili­ation				67. Date of Birth (Age)									68. Social Security Number
							Y	Y	Y	Y	M	M	D	D
	1																		-			-
	2																		-			-
	3																		-			-
	4																		-			-
	5																		-			-
	6																		-			-
	7																		-			-
	8																		-			-

Child			66. Family Affili­ation				67. Date of Birth (Age)									68. Social Security Number
							Y	Y	Y	Y	M	M	D	D
	9																		-			-
	10																		-			-

			69. Race/Ethnicity
			Ethnicity						Race
Child			A. 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
	7
	8
	9
	10

71. Receives Disability Benefits:

Child

70. Gender

A. Receives Benefits Based on Federal Disability Status

B. Receives Aid Under Title XVI-SSI

72. Relationship to Head of Household

73. Parent with Minor Child in the Family

74. Educational Level

1

2

							71. Receives Disability Benefits:
Child			70. Gender				A. Receives Benefits Based on Federal Disability Status					B. Receives Aid Under Title XVI-SSI					72. Relationship to Head of Household				73. Parent with Minor Child in the Family				74. Educational Level
	3
	4
	5
	6
	7
	8
	9
	10

Child			75. Citizenship / Alienage						76. Amount of Unearned Income
									A. SSI						B. Other Unearned Income
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10

OMB Number 0970-0215 - Expiration Date: xx/xx/xxxx TRIBAL TANF DATA REPORT - SECTION 1 Page 3