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Form OFA-100, the Emergency Fund Request Form

Published: August 27, 2013
Audience:
Temporary Assistance for Needy Families (TANF)
Topics:
Emergency Fund
Types:
Reporting Forms
Tags:
Form OFA-100, TANF Emergency Fund

 


Jurisdiction:                                                                   Date of Completion:      

 

Request Year FY 2009

Which quarters have revised data?                Q1                         Q2                         Q3                       Q4

Category

Quarter 1
(Oct 2008-Dec 2008)

Quarter 2
(Jan 2009-Mar 2009)

Quarter 3
(Apr 2009-Jun 2009)

Quarter 4
(Jul 2009-Sep 2009)

Assistance Caseload

     

     

     

     

Expenditures

Basic Assistance

     

     

     

     

Non-Recurrent
Short-Term Benefits

     

     

     

     

Subsidized Employment

     

     

     

     

Request Year FY 2010

Which quarters have revised data?                Q1                         Q2                         Q3                       Q4

Category

Quarter 1
(Oct 2009-Dec 2009)

Quarter 2
(Jan 2010-Mar 2010)

Quarter 3
(Apr 2010-Jun 2010)

Quarter 4
(Jul 2010-Sep 2010)

Assistance Caseload

     

     

     

     

Expenditures

Basic Assistance

     

     

     

     

Non-Recurrent
Short-Term Benefits

     

     

     

     

Subsidized Employment

     

     

     

     

Administrative Expenditures

Expenditure category

Did you include administrative
costs in this category?

Did you include them in the
base-year quarters?
Basic assistance

       yes    no

       yes    no

Non-recurrent short-term benefits

       yes    no


       yes    no

Subsidized employment

       yes    no


       yes    no

 

PART 2- EXPENDITURE INCREASES

Jurisdiction:                                                                                         Date of Completion:_

For each category in which you are requesting emergency funds, briefly describe the programs within the expenditure category.  Then describe the reasons for the expenditure increase in the quarters for which you are requesting funding compared to the corresponding base quarters.  If you are using estimated data, include the basis for the estimate.

Basic assistance expenditures consist of:

     

Basic assistance expenditure increases are due to:

 

The method for estimating any expenditures is:

     

 

Non-recurrent short-term benefit expenditures consist of:

     

Non-recurrent short-term benefit expenditure increases are due to:

 

The method for estimating any expenditures is:

     

Subsidized employment expenditures consist of:

     

Subsidized employment expenditure increases are due to:

     

The method for estimating any expenditures is:

PART 3- PROGRAM CONFIGURATION


Jurisdiction:                                                                                               Date of Completion:       _

 

Section A – Program Configuration Changes

Answer each question in this section with each quarterly request for emergency funds

1.      Since October 1, 2006, has the jurisdiction made any changes in the groups of families receiving assistance in its TANF/SSP-MOE program that are the result of changes to a solely State-funded (SSF) program – either by starting or expanding a SSF, or by ending or scaling back a SSF?

       yes    no

      If yes, have you completed Section B on a prior submission to account fully for these changes?

       yes    no

2.      Since October 1, 2006, has the jurisdiction converted any part of a program that provides non-assistance benefits (including non-recurrent short-term benefits) to a basic assistance program or converted any part of a basic assistance program to one that provides non-assistance benefits? 

       yes    no

      If yes, have you completed Section B on a prior submission to account for these changes?

       yes    no

3.      Since October 1, 2006, has the jurisdiction converted either a subsidized employment or a non-recurrent short term benefit program that operated outside of TANF/SSP-MOE to one that is within TANF?

       yes    no

      If yes, have you completed Section B on a prior submission to account for these changes?

       yes    no

4.      Since October 1, 2006, are expenditures in any of your Emergency Fund categories subject to uneven claiming across quarters?  For example, do you pay a contractor in a quarter to provide a service or benefit throughout the year but do not pay that contractor in the same quarter each year?

       yes    no

      If yes, have you completed Section B on a prior submission to account for these changes?

       yes    no

5.      Since October 1, 2006, has the jurisdiction made any other changes that resulted in a change of funding between a TANF/SSP-MOE program and a SSF program or resulted in a funding change across any of the three categories?

       yes    no

      If yes, have you completed Section B on a prior submission to account for these changes?

       yes    no



 

 

Jurisdiction:                                                                                Date of Completion:_

If yes, have you completed Section B on a prior submission to account for these changes?

yes    no

 

Section B – Adjustments for Program Configuration Changes

Change # 1

Description of program change: 

     

 

Date program change took effect:

     

 

Explanation of the methodology:

Describe why the program change requires an adjustment and how you estimated the adjustment.  Be sure to provide documentation to support the adjustments you are proposing to the assistance caseload and expenditure data.

     

Section B – Adjustments for Program Configuration Changes

Change # 2

Description of program change: 

     

 

Date program change took effect:

     

 

Explanation of the methodology:

Describe why the program change requires an adjustment and how you estimated the adjustment.  Be sure to provide documentation to support the adjustments you are proposing to the assistance caseload and expenditure data.

     

Section B – Adjustments for Program Configuration Changes

Change # 3

Description of program change: 

     

 

Date program change took effect:

     

 

Explanation of the methodology:

Describe why the program change requires an adjustment and how you estimated the adjustment.  Be sure to provide documentation to support the adjustments you are proposing to the assistance caseload and expenditure data.

     

 

 

 

Jurisdiction:                                                                                      Date of Completion:       _

 

FY 2007 Base-Year Data

Which quarters have revised data?       Q1                    Q2                   Q3                   Q4

Average Monthly Assistance Caseload

Quarter 1
(Oct 2006-Dec 2006)

Quarter 2
(Jan 2007-Mar 2007)

Quarter 3
(Apr 2007-Jun 2007)

Quarter 4
(Jul 2007-Sep 2007)

FY 2007

Unadjusted Caseload

     

     

     

     

 

           Total Adjustments

     

     

     

     

 

Adjusted Caseload

0

0

0

0

0

 

Which quarters have revised data?       Q1                    Q2                   Q3                   Q4

Basic Assistance Expenditures

Quarter 1
(Oct 2006-Dec 2006)

Quarter 2
(Jan 2007-Mar 2007)

Quarter 3
(Apr 2007-Jun 2007)

Quarter 4
(Jul 2007-Sep 2007)

FY 2007

Unadjusted Expenditures

     

     

     

     

 

           Total Adjustments

     

     

     

     

 

Adjusted Expenditures

$0

$0

$0

$0

 

 

Which quarters have revised data?       Q1                    Q2                   Q3                   Q4

Non-Recurrent Short-Term Expenditures

Quarter 1
(Oct 2006-Dec 2006)

Quarter 2
(Jan 2007-Mar 2007)

Quarter 3
(Apr 2007-Jun 2007)

Quarter 4
(Jul 2007-Sep 2007)

FY 2007

Unadjusted Expenditures

     

     

     

     

 

           Total Adjustments

     

     

     

     

 

Adjusted Expenditures

$0

$0

$0

$0

$0

 

Which quarters have revised data?       Q1                    Q2                   Q3                   Q4

Subsidized Employment Expenditures

Quarter 1
(Oct 2006-Dec 2006)

Quarter 2
(Jan 2007-Mar 2007)

Quarter 3
(Apr 2007-Jun 2007)

Quarter 4
(Jul 2007-Sep 2007)

FY 2007

Unadjusted Expenditures

     

     

     

     

 

           Total Adjustments

     

     

     

     

 

Adjusted Expenditures

$0

$0

$0

$0

$0


 

Jurisdiction:                                                                                     Date of Completion:       _

 

FY 2008 Base-Year Data

Which quarters have revised data?       Q1                    Q2                   Q3                   Q4

Average Monthly Assistance Caseload

Quarter 1
(Oct 2007-Dec 2007)

Quarter 2
(Jan 2008-Mar 2008)

Quarter 3
(Apr 2008-Jun 2008)

Quarter 4
(Jul 2008-Sep 2008)

FY 2008

Unadjusted Caseload

     

     

     

     

 

           Total Adjustments

     

     

     

     

 

Adjusted Caseload

0

0

0

0

0

 

Which quarters have revised data?       Q1                    Q2                   Q3                   Q4

Basic Assistance Expenditures

Quarter 1
(Oct 2007-Dec 2007)

Quarter 2
(Jan 2008-Mar 2008)

Quarter 3
(Apr 2008-Jun 2008)

Quarter 4
(Jul 2008-Sep 2008)

FY 2008

Unadjusted Expenditures

     

     

     

     

 

           Total Adjustments

     

     

     

     

 

Adjusted Expenditures

$0

$0

$0

$0

 

 

Which quarters have revised data?       Q1                    Q2                   Q3                   Q4

Non-Recurrent Short-Term Expenditures

Quarter 1
(Oct 2007-Dec 2007)

Quarter 2
(Jan 2008-Mar 2008)

Quarter 3
(Apr 2008-Jun 2008)

Quarter 4
(Jul 2008-Sep 2008)

FY 2008

Unadjusted Expenditures

     

     

     

     

 

           Total Adjustments

     

     

     

     

 

Adjusted Expenditures

$0

$0

$0

$0

$0

 

Which quarters have revised data?       Q1                    Q2                   Q3                   Q4

Subsidized Employment Expenditures

Quarter 1
(Oct 2007-Dec 2007)

Quarter 2
(Jan 2008-Mar 2008)

Quarter 3
(Apr 2008-Jun 2008)

Quarter 4
(Jul 2008-Sep 2008)

FY 2008

Unadjusted Expenditures

     

     

     

     

 

           Total Adjustments

     

     

     

     

 

Adjusted Expenditures

$0

$0

$0

$0

$0

 

 

Jurisdiction:                                                                                        Date of Completion      _

 

You must complete a certification with each request for emergency funds.

Certification

I certify that:

(1) this request includes all expenditure and caseload data for the fiscal quarters for which we are requesting emergency funds and (if applicable) for the base years of FY 2007 and FY 2008;

(2) the data in this request are accurate;

(3) if the request includes estimated data, the estimates are reasonable; and

(4) the request includes adjustments for all program configuration changes that would affect quarterly comparisons of the base-year and request-quarter data.

 

 

___________________________________________________________

     (signature)

(name)

(title)

 


 

Contact in the Jurisdiction

 

In the event that we have questions about any of the information in this request for emergency funds, please provide a contact with whom we can discuss them.

 

Name:                

Telephone:          

Email:                 

OMB Control No: 0970-0366  Expiration Date: 10/31/2015


 

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