2 MOE Report 2

SSP-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

4.

Year

Y

Y

Stratum

Month

Y

Y

M

M

FAMILY LEVEL DATA
5.
.

6.

Case Number - State Separate Program

Zip Code

7.

Disposition

8.

Reason for Closure

ASSISTANCE RECEIVED BY THE FAMILY
9.

Received Subsidized Housing

10.

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 209

Received Medical Assistance

11.

Received Food Stamps

SSP-MOE DATA REPORT - SECTION 2

12.

Received Subsidized
Child Care

Page 1

PERSON LEVEL DATA
13.
Person

Family
Affiliation

14.

Date of Birth (Age)

Y

Y

Y

Y

M

15.
M

D

Social Security Number

D

1

-

-

2

-

-

3

-

-

4

-

-

5

-

-

6

-

-

7

-

-

8

-

-

9

-

-

10

-

-

11

-

-

12

-

-

13

-

-

14

-

-

15

-

-

16

-

-

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 204

SSP-MOE DATA REPORT - SECTION 2

Page 2

16. Race/Ethnicity

Person

A.

Ethnicity

Race

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
11
12
13
14
15
16

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 204

SSP-MOE DATA REPORT - SECTION 2

Page 3

Person

17.

Gender

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

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 204

SSP-MOE DATA REPORT - SECTION 2

Page 4

20.
Person

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 204

SSP-MOE DATA REPORT - SECTION 2

Page 5

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 0970-0199 - Expiration Date: 06/30/2002
ACF - 204

SSP-MOE DATA REPORT - SECTION 2

Page 6