Publication Date:
September 17, 2012
Current as of:
OMB #0970-0167
Expires: 7-31-2018
Head of Family Receiving Assistance
| QUESTION NUMBER | QUESTION | RESPONSE | ||
|---|---|---|---|---|
| 1. | Reporting Period | YYYYMM | ||
|
2 |
Unique State Identifier (required in absence of SSN#) | |||
|
3 |
Social Security Number (optional) | XXX-XX-XXXX | ||
|
4. |
FIPS Codes |
State: County: |
||
|
5. |
Single Parent | |||
|
6. |
Reason for Receiving Subsidized Child Care | |||
|
7. |
Total Monthly Child Care Co-payment by Family | $ _ , _ _ _ | ||
| 8. | Month/Year Child Care Assistance to the Family Started | YYYYMM | ||
|
9. |
Total Family Income | $ _ _ , _ _ _ | ||
|
10. |
Employment Including Self-Employment | _ | ||
|
11. |
Cash or Other Assistance Under Title IV of the Social Security Act (TANF) | _ | ||
|
12. |
State Program for Which State Spending Is Counted Towards TANF MOE | _ | ||
|
13. |
Housing Voucher or Cash Assistance | _ | ||
|
14. |
Supplemental Nutrition Assistance Program (formerly Food Stamps) | _ | ||
|
15. |
Other Federal Cash Income Programs (such as SSI) | _ | ||
|
16. |
Family Size Used to Determine Eligibility | _ | ||
Dependent Children Receiving Child Care Assistance (One record per child)
| QUESTION NUMBER | QUESTION | RESPONSE | ||
|---|---|---|---|---|
|
17. |
Social Security Number (Optional) OR Unique State Identifier (Required in absence of SSN#) | _ | ||
|
18. |
Hispanic or Latino Ethnicity | _ | ||
|
19. |
American Indian or Alaskan Native | _ | ||
|
20. |
Asian | _ | ||
|
21. |
Black or African American | _ | ||
|
22. |
Native Hawaiian or Other Pacific Islander | _ | ||
|
23. |
White | _ | ||
|
24. |
Gender | _ | ||
|
25. |
Month/Year of Birth | YYYYMM | ||
Setting Information (One record for each setting for each child)
| QUESTION NUMBER | QUESTION | RESPONSE | ||
|---|---|---|---|---|
|
26. |
Type of Child Care | _ _ | ||
|
27. |
Total Monthly Amount Paid to Provider | _ _ _ _ | ||
|
28. |
Total Hours of Care Provided in Month | _ _ _ | ||
|
29. |
Provider FEIN | _ _-_ _ _ _ _ _ _ | ||
|
30. |
Provider Unique State ID | _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ | ||
Provider Information (One record for each provider)
| QUESTION NUMBER | QUESTION | RESPONSE | ||
|---|---|---|---|---|
|
31. |
Provider FEIN (same as item 29) | _ _-_ _ _ _ _ _ _ | ||
|
32. |
Provider Unique State ID (same as item 30) | _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ | ||
|
33. |
QRIS Participation | _ | ||
|
34. |
QRIS Rating | _ _ _ | ||
|
35. |
Accreditation Status | _ | ||
|
36. |
Provider is Subject to State Pre-K Standards | _ | ||
|
37. |
Other State-defined Quality Measure | _ | ||