SSP-MOE DATA REPORT - SECTION 2
DISAGGREGATED DATA COLLECTION FOR FAMILIES NO LONGER RECEIVING
ASSISTANCE UNDER THE STATE SEPARATE PROGRAM
GENERAL INFORMATION
1.	State FIPS Code				2.	County FIPS Code						3.	Reporting Month										4.	Stratum
													Year					Month
													Y	Y	Y	Y		M	M
FAMILY LEVEL DATA
	5.	Case Number - State Separate Program												6.	Zip Code								7.	Disposition					8.	Reason for Closure
ASSISTANCE RECEIVED BY THE FAMILY
	9.	Received Subsidized Housing								10.	Received Medical Assistance								11.	Received Food Stamps						12.	Received Subsidized Child Care
PERSON LEVEL DATA
Person			13.	Family Affiliation					14.	Date of Birth (Age)									15.	Social Security Number
									Y	Y	Y	Y	M	M	D	D
	1																					-			-
	2																					-			-
	3																					-			-
	4																					-			-
	5																					-			-
	6																					-			-
	7																					-			-
	8																					-			-
Person			13.	Family Affiliation					14.	Date of Birth (Age)									15.	Social Security Number
	9																					-			-
	10																					-			-
	11																					-			-
	12																					-			-
	13																					-			-
	14																					-			-
	15																					-			-
	16																					-			-
			16.	Race/Ethnicity
			Ethnicity						Race
Person			A.	Hispanic or Latino					B.	American Indian of Alaska Native					C.	Asian			D.	Black or African American				E.	Native Hawaiian or Pacific Islander					F.	White
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10
	11
	12
	13
	14
	15
	16
							18.	Received Disability Benefits
Person			17.	Gender			A.	Received Federal Disability Insurance Benefits - OASDI				B.	Received Benefits Based on Federal Disability Status				C.	Received Aid Under Title XIV-APDT				D.	Received Aid Under Title XVI-AABD			E.	Received Aid Under Title XVI-SSI				19.	Marital Status
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10
	11
	12
	13
	14
	15
	16
Person			20.	Relationship to Head of Household				21.	Parent with Minor Child in the Family				22.	Needs of a Pregnant Woman				23.	Educational Level				24.	Citizenship / Alienage				25.	Employment Status
	1
	2
	3
	4
	5
	6
	7
	8
Person			20.	Relationship to Head of Household				21.	Parent with Minor Child in the Family				22.	Needs of a Pregnant Woman				23.	Educational Level				24.	Citizenship / Alienage				25.	Employment Status
	9
	10
	11
	12
	13
	14
	15
	16
AMOUNT OF INCOME, BY TYPE
Person				26.	Amount of Earned Income									27.	Amount of Unearned Income
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10
	11
	12
	13
	14
	15
	16

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