ACF-801 Online Help

September 18, 2012
Categories:
Child Care Development Fund (CCDF) Reporting
Topics:
ACF-801, States/Territories

*Click on the text or in the center of any yellow box to receive help on that field

ACF - 801 Child Care Quarterly Case Record Form

OMB #: 0970-0167 Expires: 04/30/2015

Head of Family Receiving Assistance
1. Reporting Period Month/Year  
2. Unique State Identifier (required in absence of SSN#)
3. Social Security Number (optional)
4. FIPS Codes
5. Single Parent
6. Reason for Receiving Care
7. Total Monthly Child Care Co-payment by Family
8. Month/Year Child Care Assistance to the Family Started
9. Total Monthly Family Income for Determining Eligibility

Family Income Sources

(Y/N)

10. Employment Including Self-Employment

11. Cash or Other Assistance Under Title IV of the Social Security Act (TANF)

12. State Program for Which State Spending Is Counted Towards TANF MOE

13. Housing Voucher or Cash Assistance

14. Assistance Under the Food Stamps Act of 1977
15. Other Federal Cash Income Programs (such as SSI)
16. Number in Eligible Family (Required as of 04/01/02)  

Dependent Children Receiving Child Care Assistance

Child Receiving Care 17.
Social Security Number (0ptional)		 18.
Hispanic
or Latino		 19.
American Indian or Alaskan Native		 20.
Asian		 21.
Black or
African American		 22.
Native Hawaiian or Other Pacific Islander		 23.
White		 24.
Gender		 25.
Month/Year of Birth		 26.
Type of Child Care		 27.
Total Monthly Amount Paid to Provider		 28.
Total Hours
of Care
Provided in Month
Child 1  

Child 1, Provider 1

Child 1, Provider 2

Child 2

  

Child 2, Provider 1

Child 2, Provider 2

 

 

Child 3

  

Child 3, Provider 1

Child 3, Provider 2

Child 4

  

Child 4, Provider 1

Child 4, Provider 2