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ACF - 801 Child Care Quarterly Case Record Form

ACF - 801 Child Care Quarterly Case Record Form

OMB #:

Date:

 

  1. Head of Family Receiving Assistance
  1. Reporting Period

Month:  

Year:    

  • Unique State Identifier (Optional)

    •               

  • Social Security Number

    •    -   -    

  • FIPS Codes

    • State:  

    County:   

  • Single Parent (Y/N)

    • 

  • Reason for Receiving Care

    • 

  • Total Monthly Child Care Copayment by Family

    • $  ,   

  • Month/Year Child Care Assistance to the Family Started

    • Month:  

    Year:    

  • Total Monthly Family Income for Determining Eligibility

    • $   ,   

    1. Family Income Sources

    Income Source

    (Y/N)

    1. Employment Including Self-Employment

    

  • Cash or Other Assistance Under Title IV of the Social Security Act (Temporary Assistance to Needy Families)

    • 

  • State Program for Which State Spending Is Counted Towards Temporary Assistance to Needy Families MOE

    • 

  • Housing Voucher or Cash Assistance

    • 

  • Assistance Under the Food Stamps Act of 1977

    • 

  • Other Federal Cash Income Programs (such as SSI)

    • 

    1. Dependent Children Receiving Child Care Assistance

    Child Receiving Care

    1. Social Security Number (optional)

    2. Race

    3. Gender

    4. Month/Year of Birth

    (month)          (year)

    5. Type of Child Care

    6. Total Monthly Amount Paid to Provider

    7. Total Hours of Care Provided in Month

    Child 1

       -   -    

    

    

     

       

     

    $  ,   

      

    Caregiver 2

     

    $  ,   

      

    Caregiver 3

     

    $  ,   

      

    Child 2

       -   -    

    

    

     

       

     

    $  ,   

      

    Caregiver 2

     

    $  ,   

      

    Caregiver 3

     

    $  ,   

      

    Child 3

       -   -    

    

    

     

       

     

    $  ,   

      

    Caregiver 2

     

    $  ,   

      

    Caregiver 3

     

    $  ,   

      

    Child 4

       -   -    

    

    

     

       

     

    $  ,   

      

    Caregiver 2

     

    $  ,   

      

    Caregiver 3

     

    $  ,   

      

    Child 5

       -   -    

    

    

     

       

     

    $  ,   

      

    Caregiver 2

     

    $  ,   

      

    Caregiver 3

     

    $  ,   

      

    Child 6

       -   -    

    

    

     

       

     

    $  ,   

      

    Caregiver 2

     

    $  ,   

      

    Caregiver 3

     

    $  ,