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Attachment A – 102-477 Child Count Declaration

CCDF-ACF-PI-2013-04

Published: October 10, 2013
Categories:
Program Administration
Topics:
Tribes
Types:
Form

CHILD COUNT DECLARATION

(P.L. 102-477 Tribe)

Federal Fiscal Year: YYYY

Name of Tribe/Tribal Lead Agency: ___________

This certifies that the number of Indian children under age 13 (as defined in the CCDF section of the 102-477 plan) who reside on or near the reservation or service area (as defined in the CCDF section of the 102-477 plan) is: ________(number)

The Tribe/Tribal Lead Agency may not count any children who are included in the Child Count of another CCDF Tribe/Tribal Lead Agency. To ensure unduplicated child counts, a Tribe/Tribal Lead Agency is required to confer with all other CCDF Tribe/Tribal Lead Agencies that have overlapping or neighboring service areas.

This count shows the number of Indian children under age 13 as of date: MM/DD/YYYY

Official Signature of Individual Authorized to Act for the Tribe


____________________________________________________

Date: MM/DD/YYYY

Type or Write Name and Title:

________________________________________________________________________________

REQUEST FOR REALLOTTED TRIBAL DISCRETIONARY FUNDS

The Tribe named above requests Discretionary Funds that may be available through the reallotment process.

____Yes             ____ No