Form 1 MOE Report 1

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Overview

SSP-MOE Section 1 Page1
SSP-MOE Section 1 page 2
SSP-MOE Section 1 page 3
SSP-MOE Section 1 page 4
SSP-MOE Section 1 page 5
SSP-MOE Section 1 page 6
SSP-MOE Section 1 page 7
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SSP-MOE Section 1 page 9
SSP-MOE Section 1 page 10

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Sheet 1: SSP-MOE Section 1 Page1

SSP MOE DATA REPORT - SECTION 1

DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER THE

STATE SEPARATE PROGRAMS

GENERAL INFORMATION

3.

Reporting Month

1.

State FIPS Code

2.

County FIPS Code

Year

Month

4.

Stratum

Y

Y

Y

Y

M

M

FAMILY LEVEL DATA

5.

Case Number - Separate State MOE

6.

ZIP Code

7.

Disposition

8.

Number of Family Members

9.

Type of Family for Work Participation

ASSISTANCE RECEIVED BY THE FAMILY

10.

Has the Family Received Assistance Under a State (Tribal) TANF Program Within the Past Six Months

11.

Has the Family Received Assistance Under a State (Tribal) TANF Program Within the Past Six Months

12.

Receives Medical Assistance

13.

Receives Food Stamps

14.

Amount of Food Stamps Assistance

15.

Receives Subsidized Child Care

16.

Amount of Subsidized Child Care

17.

Amount of Child Support

18.

Amount of the Family's Cash Resources

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Sheet 2: SSP-MOE Section 1 page 2

AMOUNT OF ASSISTANCE RECEIVED AND THE NUMBER OF MONTHW THAT THE FAMILY HAS RECEIVED EACH TYPE OF ASSISTANCE UNDER STATE SEPARATE PROGRAMS

19.

Cash and Cash Equivalent

A.

Amount

B.

Number of Months

20.

Child Care

21.

Transportation

A.

Amount

B.

Number of Children Covered

C.

Number of Months

A.

Amount

B.

Number of Months

22.

Transitional Services

23.

Other Assistance

A.

Amount

B.

Number of Months

A.

Amount

B.

Number of Months

REASON FOR AND AMOUNT OF REDUCTION IN ASSISTANCE

24.

Reason for and Amount of Reduction In Assistance:

A.:

Sanctions:

i.

Total Dollar Amount of 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 in Child Support

vi.

Failure to Comply with Individual Responsibility Plan

vii.

Other Sanction

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Sheet 3: SSP-MOE Section 1 page 3

								C.	Other:
	B.	Recoupment of Prior Overpayment						i.	Total Dollar Amount of Reductions Due to Other Reasons (excludes Sanctions and Recoupment)									ii.	Family Cap			iii.	.Reduction Based on Length of Receipt of Assistance						iv.	Other, Non-sanction
25.	Waiver Evaluation Experimental and Control Group
PERSON LEVEL DATA
ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS
Adult														28.	Date of Birth (Age)
			26.	Family Affiliation			27.	Non-Custodial Parent Indicator						Y	Y	Y	Y	M	M	D	D		29.	Social Security Number
	1																									-			-
	2																									-			-
	3																									-			-
	4																									-			-
	5																									-			-
	6																									-			-

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Sheet 4: SSP-MOE Section 1 page 4

30.

Race/Ethnicity

Ethnicity

Race

Adult

A.

Hiispanic 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

32.

Receives Disability Benefits

Adult

31.

Gender

A.

Receives Federal Disability Insurance Benefits

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

33.

Marital Status

1

2

3

4

5

6

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Sheet 5: SSP-MOE Section 1 page 5

Adult		34.	Relation to Head of Household				35.	Parent with Minor Child in Family				36.	Needs of a Pregnant Woman					37.	Educational Level					38.	Citizen-ship / Alienage
	1
	2
	3
	4
	5
	6
Adult			39.	Cooperation in Child Support					40.	Employment Status				41.	Work-Eligible Individual Indicator						42.	Work Participation Status
	1
	2
	3
	4
	5
	6

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Sheet 6: SSP-MOE Section 1 page 6

ADULT WORK PARTICIPATION ACTIVITIES
Adult																		46.	Work Experience
			43.	Unsubsidized Employment				44.	Subsidized Private Sector				45.	Subsidized Public Sector				A.	Hours of Participation			B.	Excused Absences			C.	Holidays				47.	On-the-Job Training
	1
	2
	3
	4
	5
	6
Adult			48.	Job Search and Job Readiness Assistance																	49.	Community Service Programs
			A.	Hours of Participation			B.	Excused Absences			C.	Holidays									A.	Hours of Participation			B.	Excused Absences			C.	Holidays
	1
	2
	3
	4
	5
	6

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Sheet 7: SSP-MOE Section 1 page 7

50.

Vocational Educational Training

51.

Job Skills Training Directly Related to Employment

A.

Hours of Participation

B.

Excused Absences

C.

Holidays

A.

Hours of Participation

B.

Excused Absences

C.

Holidays

1

2

3

4

5

6

52.

Education Directly Related to Employment for Individuals with No High School Diploma or Certificate of High School Equivalency

53.

Satisfactory School Attendance for Individuals with No High School Diploma or Certificate of High School Equivalency

A.

Hours of Participation

B.

Excused Absences

C.

Holidays

A.

Hours of Participation

B.

Excused Absences

C.

Holidays

1

2

3

4

5

6

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Sheet 8: SSP-MOE Section 1 page 8

					54.	Providing Child Care Services to an Individual Who is Participating in a Community Service Program
Adult					A.	Hours of Participation			B.	Excused Absences			C.	Holidays				55.	Other Work Activities				56.	Number of Deemed Core Hours for Overall Rate					57.	Number of Deemed Core Hours for Two-Parent Rate
	1		1
	2		2
	3		3
	4		4
	5		5
	6		6
AMOUNT OF INCOME, BY TYPE
								59.	Amount of Unearned Income
Adult			58.	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

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Sheet 9: SSP-MOE Section 1 page 9

CHILD CHARACTERISTICS
Child										61.	Date of Birth (Age)
			60.	Family Affiliation						Y	Y	Y	Y	M	M	D	D		62.	Social Security Number
	1																					-			-
	2																					-			-
	3																					-			-
	4																					-			-
	5																					-			-
	6																					-			-
	7																					-			-
	8																					-			-
	9																					-			-
	10																					-			-
			63.	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

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Sheet 10: SSP-MOE Section 1 page 10

							65.	Receives Disability Benefits:
Child			64.	Gender			A.	Receives Benefits Based on Federal Disability Status						B.	Receives Aid Under Title XVI-SSI					66.	Relationship to Head of Household				67.	Parent with Minor Child in the Family				68.	Educational Level
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10
									70.	Amount of Unearned Income
Child			69.	Citizenship / Alienage					A.	SSI					B.	Other Unearned Income
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10