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pdfSSP-MOE DATA REPORT - SECTION 2
DISAGGREGATED DATA COLLECTION FOR FAMILIES NO LONGER RECEIVING
ASSISTANCE UNDER THE STATE SEPARATE PROGRAM
GENERAL INFORMATION
1.
State FIPS Code
2.
County FIPS Code
3.
Reporting Month
Year
Y
4.
Stratum
7.
Disposition
Month
Y
Y
Y
M
M
FAMILY LEVEL DATA
5.
Case Number - State Separate Program
6.
Zip Code
8.
Reason for Closure
ASSISTANCE RECEIVED BY THE FAMILY
9.
Received Subsidized Housing
10.
Received Medical Assistance
11.
Received Food Stamps
12.
Received Subsidized Child Care
PERSON LEVEL DATA
Person
13.
Family Affiliation
14.
Y
Date of Birth (Age)
Y
Y
Y
15.
M
M
D
Social Security Number
D
1
-
-
2
-
-
3
-
-
4
-
-
5
-
-
6
-
-
7
-
-
8
-
-
OMB Number 0970-0338 - Expiration Date 04/30/2011
ACF - 209
SSP-MOE DATA REPORT - SECTION 2
Page 1
Person
13.
Family Affiliation
14.
Date of Birth (Age)
15.
Social Security Number
9
-
-
10
-
-
11
-
-
12
-
-
13
-
-
14
-
-
15
-
-
16
-
-
16.
Race/Ethnicity
Ethnicity
Person
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
11
12
13
14
15
16
OMB Number 0970-0338 - Expiration Date 04/30/2011
ACF - 209
SSP-MOE DATA REPORT - SECTION 2
Page 2
Person
17.
Gender
20.
Relationship to
Head of Household
18.
Received Disability Benefits
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
19.
Marital Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Person
21.
Parent with Minor
Child in the Family
22.
Needs of a
Pregnant Woman
23.
Educational
Level
24.
Citizenship /
Alienage
25.
Employment
Status
1
2
3
4
5
6
7
8
OMB Number 0970-0338 - Expiration Date 04/30/2011
ACF - 209
SSP-MOE DATA REPORT - SECTION 2
Page 3
Person
20.
Relationship to
Head of Household
21.
Parent with Minor
Child in the Family
22.
Needs of a
Pregnant Woman
23.
Educational
Level
24.
Citizenship /
Alienage
25.
Employment
Status
9
10
11
12
13
14
15
16
AMOUNT OF INCOME, BY TYPE
Person
26.
Amount of Earned Income
27.
Amount of Unearned Income
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
OMB Number 0970-0338 - Expiration Date 04/30/2011
ACF - 209
SSP-MOE DATA REPORT - SECTION 2
Page 4
| File Type | application/pdf |
| File Title | TDR_reports_10_1_2008_ssp2.xls |
| Author | ajsaulnier |
| File Modified | 2008-08-05 |
| File Created | 2008-08-05 |