Complete Name of Grantee:

Address:

Contact Person, phone, email:

( A )

TOTAL

Payment Methods:
3. Number of children served through grants or contracts

4. Number of children receiving child care services through certificates and/or cash

5. Of children served through certificates, number of children served through cash payments

6a. Number of child care providers receiving CCDF funding by type of care

6b. Total licensed capacity in centers and homes (No longer collected as of FFY 2003)

7. Estimated number of families receiving consumer education

How is the estimated number of families receiving consumer education determined?

Below, Indicate Methods Used on a Regular Basis:

8. Information to subsidized families concerning the choice of a certificate or grant/contract

9. Resource and referral counseling

10. List of legally operating child care providers

11. Brochure, booklet or written material about types of care and quality of care

12. Checklist of health and safety concerns

13. Copies of child care regulatory information

14. Familiarization with child care provider complaint policies (any method)

15. Mass media such as: television, radio, internet sites, billboards, etc.

16. Other (Please explain in next field)

CCDF Funds:

Do you include Pre-K funds as part of Match or MOE:

Y [    ] State funds used to match Federal funds
N [    ] MOE funds?

Non-CCDF Funds:

Y [    ] N [    ] Title XX

Y [    ] N [    ] State-only child care funds

Y [    ] N [    ] Welfare to Work

Y [    ] N [    ] Title IV-B or Title IV-E

Y [    ] N [    ] Private/donated funds

Y [    ] N [    ] Food Stamp child care funds

Y [    ] N [    ] Non-compulsory school funds

Y [    ] N [    ] TANF funds not transferred into Discretionary Fund

Y [    ] N [    ] HUD child care funds

Y [    ] N [    ] Other: ____________________________________