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 ________________________________

Prepared by:

Name ___________________________________________
Title ____________________________________________
Signature ___________________________________________

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]

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

A. by COUNTY

B. by LOCAL EDUCATIONAL AGENCY (LEA)

County name FIPS County Code Number