Final Tribal TANF Data Report

TRIBAL 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. Stratum
																		Year					Month
																		Y	Y	Y	Y		M	M

FAMILY LEVEL DATA

6. Case Number - TANF

7. ZIP Code

8. Disposition

9. 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. Date of Birth (Age)										16. Social Security Number
						Y	Y	Y	Y	M	M	D	D
	1																		-			-
	2																		-			-
	3																		-			-
	4																		-			-
	5																		-			-
	6																		-			-
	7																		-			-
	8																		-			-
	9																		-			-
	10																		-			-
	11																		-			-
	12																		-			-
	13																		-			-
	14																		-			-
	15																		-			-
	16																		-			-

			17. Race/Ethnicity
			Ethnicity						Race
Person			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
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							19. Received Disability Benefits
Person			18. Gender				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
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	2
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Person			20. Marital Status				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
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Person			26. Number of Months Countable Toward Federal Time Limit							27. Number of Countable Months Remaining Under State's (Tribe's) Time Limit									28. Employment Status
	1
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AMOUNT OF INCOME, BY TYPE

Person				29. Amount Earned Income										30. Amount of Unearned Income
	1
	2
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	5
	6
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	9
	10
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	12
	13
	14
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	16

OMB Number 0970-0215 - Expiration Date: xx/xx/xxxx Tribal TANF DATA REPORT - SECTION 2 Page 7