DEPARTMENT OF HEALTH AND HUMAN SERVICES	OMB Approval No.:  0970-0004
Administration for Children and Families	Expires:  11/30/2008
Form ACF-4125	DESTROY PRIOR EDITIONS
ANNUAL STATISTICAL REPORT ON
CHILDREN IN FOSTER HOMES AND CHILDREN IN FAMILIES RECEIVING PAYMENTS
IN EXCESS OF THE POVERTY INCOME LEVEL
FROM A STATE PROGRAM FUNDED UNDER PART A OF
TITLE IV OF THE SOCIAL SECURITY ACT
State __________________________________	State Agency ___________________________
Report for the month of October 2008
Prepared by:
Name __________________________________________________
Title ___________________________________________________
Signature_______________________________________________
Compiled by:
Name __________________________________________________
Phone # ________________________________________________
Email address____________________________________________
Part I.
NUMBER OF CHILDREN AGED 5-17 IN FOSTER HOMES
State total _______________
(if entry is greater than zero (0), attach a separate list  in the following format.)
Children Aged 5-17 in Foster Homes
A.  by COUNTY	B.  by LOCAL EDUCATIONAL AGENCY (LEA)
County name FIPS County Code Number	LEA name LEA Code (Agency ID) Number
Part II.
NUMBER OF CHILDREN AGED 5-17 IN FAMILIES RECEIVING PAYMENTS IN EXCESS OF
THE AMOUNT SPECIFIED FOR THIS REPORT PERIOD FROM A STATE PROGRAM FUNDED UNDER
PART A OF TITLE IV OF THE SOCIAL SECURITY ACT
State total _______________
(if entry is greater than zero (0), attach a separate list  in the following format.)
Children Aged 5-17 in FAMILIES RECEIVING PAYMENTS IN EXCESS OF $1,766.67
A.  by COUNTY	B.  by LOCAL EDUCATIONAL AGENCY (LEA)
County name FIPS County Code Number	LEA name LEA Code Number