Form 1 SSP-MOE Data Report Form - Part 265

TANF DATA REPORT - SECTION 1
TANF DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER
THE TANF PROGRAM

GENERAL INFORMATION

4.
1.

State FIPS Code

2.

County FIPS Code

3.

Tribal Code
(For Tribal Use Only)

Reporting Month
Year

Y

5.

Stratum

18.

Amount of Subsidized Child
Care

Month

Y

Y

Y

M

M

FAMILY LEVEL DATA
6.

Case Number - TANF

8.

Funding Stream

9.

Disposition

10.

New Applicant

7.

ZIP Code

11.

Number of Family Members

12.

Type of Family for Work
Participation

ASSISTANCE RECEIVED BY THE FAMILY
13.

Receives Subsidized
Housing

19.

Amount of Child Support

14.

Receives Medical
Assistance

20.

15.

Receives Food Stamps

16.

Amount of Food Stamps
Assistance

17.

Receives Subsidized
Child Care

Amount of the Family's Cash Resources

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering information to assess and evaluate whether a State
TANF program meets statutorily required participation rates. Public reporting burden for this collection of information is estimated to average 8,804 hours per grantee per year, including the time for reviewing
instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (42 U.S.C. § 611). An agency may not conduct or sponsor, and
a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is
0970-0338 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact the Office of Family Assistance by email at TANFdata@acf.hhs.gov.

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
ACF - 199

TANF DATA REPORT - SECTION 1

Page 1

AMOUNT OF ASSISTANCE RECEIVED AND THE NUMBER OF MONTHS THAT THE FAMILY HAS RECEIVED
EACH TYPE OF ASSISTANCE UNDER STATE (TRIBAL) TANF PROGRAM

21.

Cash and Cash Equivalent

A.

Amount

22.

TANF Child Care

A.

Amount

24.

Transitional Services
A.

B.

Number of Months

23.
Number of Children
Covered

B.

C.

Number of Months

A.

25.

Amount

B.

. Transportation

Number of Months

Amount

B.

Number of Months

B.

Number of Months

Other Assistance
A.

Amount

REASON FOR AND AMOUNT OF REDUCTION IN ASSISTANCE
26.

27.

Reason and Amount of Reduction in Assistance
A.

Sanctions:

i.

Total Dollar Amount for
Reduction Due to
Sanctions

B.

Recoupment of Prior Overpayment

ii.

Waiver Evaluation Research Group

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
ACF - 199

Work Requirements
Sanction

28.

iii.

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

iv.

C.

Other

i.

Total Dollar Amount of Reduction Due to Other Reasons

Failure to Comply with an
Individual Responsibility
Plan

Sanction for Teen Parent
Not Attending School

v.

Non-cooperation
with Child Support

Family Cap

iii.

Reduction Based on Length of
Receipt of Assistance

ii.

Is the TANF Family Exempt from Federal Time Limit Provisions

TANF DATA REPORT - SECTION 1

29.

vi.

iv.

vii.

Other Sanction

Other, Non-sanction

Is the TANF Family a New Child-Only Family?

Page 2

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)

Y

Y

Y

Y

33.
M

M

D

Social Security Number

D

1

-

-

2

-

-

3

-

-

4

-

-

5

-

-

6

-

-

34. Race/Ethnicity
Ethnicity
Adult

A.

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

36.
Adult

35. Gender

A.

Receives Disability Benefits
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

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TANF DATA REPORT - SECTION 1

Page 3

Adult

37. Marital Status

38.

Relationship to
Head of Household

44.

Number of Months
Countable Toward Federal
Time Limit

39.

Parent with Minor
Child in the Family

40.

Needs of a Pregnant
Woman

41.

Educational Level

47.

Employment Status

42.

Citizenship / Alienage

1
2
3
4
5
6

Adult

43.

Cooperation in Child
Support

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

48.

Work-Eligible
Individual Indicator

49.

Work Participation

54.

On-the-Job
Training

1
2
3
4
5
6

ADULT WORK PARTICIPATION ACTIVITIES
Adult

53.
50.

Unsubsidized
Employment

51.

Subsidized Private Sector
Employment

52.

Subsidized Public Sector
Employment

A.

Work Experience
Hours of
Participation

B.

Excused
Absences

C. Holidays

1
2
3
4
5
6

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 1

Page 4

Adult

55. Job Search and Job Readiness Assistance
A.

Hours of
Participation

B.

Excused
Absences

56.
C. Holidays

Community Service Programs
A.

Hours of
Participation

B.

Excused
Absences

C. Holidays

1
2
3
4
5
6

Adult

57. Vocational Educational Training
A.

Hours of
Participation

B.

Excused
Absences

58.
C. Holidays

Job Skills Training Directly Related to Employment
A.

Hours of
Participation

B.

Excused
Absences

C. Holidays

1
2
3
4
5
6

Adult

59.

A.

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

B.

Excused
Absences

C. Holidays

60.

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

1
2
3
4
5
6

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 1

Page 5

Adult

61.
A.

Providing Child Care Services to an Individual Who is Participating in a
Community Service Program
Hours of
Participation

B.

Excused
Absences

C. Holidays

62

Other Work Activities

63

Number of Deemed Core Hours for
Overall Rate

64

Number of Deemed Core Hours for the
Two-Parent Rate

1
2
3
4
5
6

AMOUNT OF INCOME, BY TYPE

66.
Adult

Amount of Unearned Income

65.

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

Adult
1
2
3
4
5
6

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 1

Page 6

CHILD CHARACTERISTICS

Child

68.
67. Family Affiliation

Y

Date of Birth (Age)
Y

Y

Y

M

M

D

D

69.

Social Security Number

1

-

-

2

-

-

3

-

-

4

-

-

5

-

-

6

-

-

7

-

-

8

-

-

9

-

-

10

-

-

70. Race/Ethnicity
Ethnicity
Child

A.

Race
Hispanic or Latino

B.

American Indian or 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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Child

71. Gender

72.

Receives Disability Benefits:

A.

Receives Benefits Based on
Federal Disability Status

B.

Receives Aid Under
Title XVI-SSI

73.

Relationship to
Head of Household

74.

Parent with Minor
Child in the Family

75.

Educational Level

1
2
3
4
5
6
7
8
9
10

77.

Amount of Unearned Income

A.

SSI

Child
76. Citizenship / Alienage

B.

Other Unearned Income

1
2
3
4
5
6
7
8
9
10

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 1

Page 8

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

Year

Y

Stratum

Month

Y

Y

Y

M

Disposition

9.

M

FAMILY LEVEL DATA

6.

Case Number - TANF

7.

ZIP Code

8.

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.
Y

Date of Birth (Age)
Y

Y

Y

16.
M

M

D

Social Security Number

D

1

-

-

2

-

-

3

-

-

4

-

-

5

-

-

6

-

-

7

-

-

8

-

-

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 2

Page 9

Person

14.

Family Affiliation

15.
Y

Date of Birth (Age)
Y

Y

Y

16.
M

M

D

Social Security Number

D

9

-

-

10

-

-

11

-

-

12

-

-

13

-

-

14

-

-

15

-

-

16

-

-

17.

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: XX/XX/XXXX
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TANF DATA REPORT - SECTION 2

Page 10

Person

18.

Gender

19.

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

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

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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TANF DATA REPORT - SECTION 2

Page 11

Person

20.

Marital Status

26.

Number of Months Countable Toward
Federal Time Limit

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

9
10
11
12
13
14
15
16

Person

27.

Number of Countable Months Remaining Under
State's (Tribe's) Time Limit

28.

Employment
Status

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

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Page 12

AMOUNT OF INCOME, BY TYPE

Person

29.

Amount Earned Income

30.

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: XX/XX/XXXX
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TANF DATA REPORT - SECTION 2

Page 13

TANF DATA REPORT - SECTION 3
TANF AGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER
THE TANF PROGRAM
GENERAL INFORMATION

1.

State FIPS Code

2.

Tribal Code
(For Tribal Use Only)

3.

Calendar Quarter
Year

Y

Quarter

Y

Y

Y

Q

TANF APPLICATIONS

First Month
4.

Total Number of Applications

5.

Total Number of Approved Applications

6.

Total Number of Denied Applications

Second Month

Third Month

FAMILIES RECEIVING ASSISTANCE

First Month
7.

Second Month

Third Month

Total Amount of Assistance

$

$

8.

Total Number of Families

9.

Total Number of Two-Parent Families

10.

Total Number of One-Parent Families

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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$

TANF DATA REPORT - SECTION 3

Page 14

11.

Total Number of No-Parent Families

12.

Total Number of Recipients

13.

Total Number of Adult Recipients

14.

Total Number of Child Recipients

15.

Total Number of Non-Custodial Parents Participating in Work Activities

16.

Total Number of Births

17.

Total Number of Out-of-Wedlock Births

FAMILIES NO LONGER RECEIVING ASSISTANCE

First Month
18.

Second Month

Third Month

Total Number of Closed Cases

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TANF DATA REPORT - SECTION 3

Page 15

TANF DATA REPORT - SECTION 4
NUMBER OF FAMILIES BY STRATUM FOR STATES THAT REPORT DATA BASED
ON A STRATIFIED SAMPLE
GENERAL INFORMATION

1.

State FIPS Code

2.

Tribal Code
(For Tribal Use Only)

3.

Calendar Quarter
Year

Y

Quarter

Y

Y

Y

Q

6. TOTAL NUMBER OF FAMILIES
4.

TDR Section Indicator

5.

Strarum

A. First Month

B. Second Month

C. Third Month

(1.)

(2)

(3.)

(4.)

(5.)

(6.)

(7.)

(8.)

(9.)

(10.)
OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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Page 16

(11.)

(12.)

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Page 17

SSP MOE DATA REPORT - SECTION 1
DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER THE
STATE SEPARATE PROGRAMS
GENERAL INFORMATION

3.
1.

State FIPS Code

2.

Reporting Month

County FIPS Code

Year

Y

Y

Y

Month

Y

M

4.

Stratum

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

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

15. Receives Subsidized Child Care

Has the Family Received
Assistance Under a State (Tribal)
11.
TANF Program Within the Past
Six Months

16. Amount of Subsidized Child Care

12.

Receives Medical
Assistance

17. Amount of Child Support

13.

Receives Food
Stamps

14.

Amount of Food Stamps
Assistance

18. Amount of the Family's Cash Resources

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering information to assess and evaluate whether
a Separate State Program – Maintenance of Effort (SSP-MOE) meets statutorily required participation rates. Public reporting burden for this collection of information is estimated to average 2,856
hours per grantee per year, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of
information (42 U.S.C. § 611). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction
Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0338 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information,
please contact the Office of Family Assistance by email at TANFdata@acf.hhs.gov.
OMB Number 0979-0338 - Expiration Date: XX/XX/XXXX
ACF - 209

SSP MOE DATA REPORT - SECTION 1

Page 18

AMOUNT OF ASSISTANCE RECEIVED AND THE NUMBER OF MONTH 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
A.

21. Transportation

Amount

B.

Number of Children
Covered

C.

Number of
Months

A.

22. Transitional Services
A.

Amount

B.

Number of Months

B.

Number of Months

23. Other Assistance

Amount

B.

Number of Months

A.

Amount

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

B.

Recoupment of Prior
Overpayment

ii.

Work
Requirements
Sanction

iii.

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

Sanction for
Teen Parent Not
iv.
Attending
School

C.

Other:

i.

Total Dollar Amount of Reductions Due to Other
Reasons (excludes Sanctions and Recoupment)

ii.

v.

Non-cooperation
in Child Support

Family Cap

iii.

Failure to Comply with
vi. Individual Responsibility
Plan

vii.

.Reduction Based on Length of
Receipt of Assistance

iv.

Other Sanction

Other, Nonsanction

25. Waiver Evaluation Experimental and Control Group

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Page 19

PERSON LEVEL DATA

ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS

28. Date of Birth (Age)

Adult
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

-

-

30. Race/Ethnicity
Ethnicity
Adult

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

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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 XIVAPDT

D.

Receives Aid
Under Title XVIAABD

E.

Receives Aid Under
Title XVI-SSI

33. Marital Status

1
2
3
4
5
6

Adult

34.

Relation to Head of
Household

39.

Cooperation in
Child Support

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

40. Employment Status

41. Work-Eligible Individual Indicator

42. Work Participation Status

1
2
3
4
5
6

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ADULT WORK PARTICIPATION ACTIVITIES

Adult
43.

Unsubsidized
Employment

44.

Subsidized
Private Sector

45.

Subsidized
Public Sector

46. Work Experience
Hours of
A.
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
Hours of
Excused
A.
B.
C. Holidays
Participation
Absences

49. Community Service Programs
Hours of
Excused
A.
B.
Participation
Absences

50. Vocational Educational Training
Hours of
Excused
A.
B.
Participation
Absences

51. Job Skills Training Directly Related to Employment
Hours of
Excused
A.
B.
C. Holidays
Participation
Absences

C. Holidays

1
2
3
4
5
6

Adult

C. Holidays

1
2
3
4
5
6

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Page 22

Satisfactory School Attendance for Individuals with No
53. High School Diploma or Certificate of High School
Equivalency
Hours of
Excused
A.
B.
C. Holidays
Participation
Absences

Education Directly Related to Employment for Individuals with No High
52.
School Diploma or Certificate of High School Equivalency
Adult

A.

Hours of
Participation

B.

Excused
Absences

C. Holidays

1
2
3
4
5
6

54.
Adult

A.

Providing Child Care Services to an Individual Who is
Participating in a Community Service Program
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
2
3
4
5
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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Page 24

CHILD CHARACTERISTICS
Child

61. Date of Birth (Age)
60. Family Affiliation

Y

Y

Y

Y

M

M

D

62. Social Security Number

D

1

-

-

2

-

-

3

-

-

4

-

-

5

-

-

6

-

-

7

-

-

8

-

-

9

-

-

10

-

-

63. Race/Ethnicity
Ethnicity
Child

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

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Child

64. Gender

65. Receives Disability Benefits:
Receives Benefits Based on
A.
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

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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
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

-

-

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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

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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

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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: XX/XX/XXXX
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SSP-MOE DATA REPORT - SECTION 2

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SSP-MOE DATA REPORT - SECTION 3
AGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER THE
STATE SEPARATE PROGRAM
GENERAL INFORMATION

1.

State FIPS Code

2.

Calendar Year and Quarter
Year

Y

Quarter

Y

Y

Y

Q

ACTIVE SSP CASES
First Month
3.

Total Number of SSP-MOE Families

4.

Total Number of Two-Parent Families

'5.

Total Number of One-Parent Families

6.

Total Number of No-Parent Families

7.

Total Number of Recipients

8.

Total Number of Adult Recipients

9.

Total Number of Child Recipients

10.

Total Number of Non-Custodial Parents Participating in Work Activities

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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Second Month

SSP-MOE DATA REPORT - SECTION 3

Third Month

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11.

Total Amount of Assistance

$

$

$

CLOSED SSP CASES

First Month
12.

Second Month

Third Month

Total Number of Closed Cases

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SSP-MOE DATA REPORT - SECTION 4
NUMBER OF FAMILIES BY STRATUM FOR STATES THAT REPORT DATA BASED
ON A STRATIFIED SAMPLE

GENERAL INFORMATION

1.

State Fips Code

2.

Calendar Year and Quarter
Year

Y

Quarter

Y

Y

Y

Q

5. TOTAL NUMBER OF FAMILIES

3.

SSP-MOE Data Report
Section Indicator

4. Stratum

A. First Month

B. Second Month

C. Third Month

1.

2.

3.

4.

5.

6.

7.

8.

9.
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Page 33

10.

11.

12.

OMB Number 0970-0338 - Expiration Date: XX/XX/XXXX
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SSP-MOE DATA REPORT - SECTION 4

Page 34