Jurisdiction: Date of Completion:
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Which quarters have revised data? Q1 Q2 Q3 Q4 |
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Category |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
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Assistance Caseload |
|
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Expenditures |
Basic Assistance |
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Non-Recurrent |
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Subsidized Employment |
Request Year FY 2010
Which quarters have revised data? Q1 Q2 Q3 Q4 |
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Category |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
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Assistance Caseload |
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Expenditures |
Basic Assistance |
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Non-Recurrent |
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Subsidized Employment |
Administrative Expenditures
Expenditure category |
Did you include administrative |
Did you include them in the base-year quarters? |
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Basic assistance | ||
Non-recurrent short-term benefits |
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Subsidized employment |
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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? If yes, have you completed Section B on a prior submission to account fully for these changes? |
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? 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? 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? 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? If yes, have you completed Section B on a prior submission to account for these changes? yes no |
Jurisdiction: Date of Completion:_ |
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If yes, have you completed Section B on a prior submission to account for these changes? yes no |
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Section B – Adjustments for Program Configuration Changes |
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Change # 1 |
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Description of program change:
|
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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.
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Jurisdiction: Date of Completion: _ |
FY 2007 Base-Year Data
Which quarters have revised data? Q1 Q2 Q3 Q4 |
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Average Monthly Assistance Caseload |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
FY 2007 |
Unadjusted Caseload |
|
||||
Total Adjustments |
|
||||
Adjusted Caseload |
Which quarters have revised data? Q1 Q2 Q3 Q4 |
|||||
Basic Assistance Expenditures |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
FY 2007 |
Unadjusted Expenditures |
|
||||
Total Adjustments |
|
||||
Adjusted Expenditures |
|
Which quarters have revised data? Q1 Q2 Q3 Q4 |
|||||
Non-Recurrent Short-Term Expenditures |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
FY 2007 |
Unadjusted Expenditures |
|
||||
Total Adjustments |
|
||||
Adjusted Expenditures |
Which quarters have revised data? Q1 Q2 Q3 Q4 |
|||||
Subsidized Employment Expenditures |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
FY 2007 |
Unadjusted Expenditures |
|
||||
Total Adjustments |
|
||||
Adjusted Expenditures |
Jurisdiction: Date of Completion: _ |
FY 2008 Base-Year Data
Which quarters have revised data? Q1 Q2 Q3 Q4 |
|||||
Average Monthly Assistance Caseload |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
FY 2008 |
Unadjusted Caseload |
|
||||
Total Adjustments |
|
||||
Adjusted Caseload |
Which quarters have revised data? Q1 Q2 Q3 Q4 |
|||||
Basic Assistance Expenditures |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
FY 2008 |
Unadjusted Expenditures |
|
||||
Total Adjustments |
|
||||
Adjusted Expenditures |
|
Which quarters have revised data? Q1 Q2 Q3 Q4 |
|||||
Non-Recurrent Short-Term Expenditures |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
FY 2008 |
Unadjusted Expenditures |
|
||||
Total Adjustments |
|
||||
Adjusted Expenditures |
Which quarters have revised data? Q1 Q2 Q3 Q4 |
|||||
Subsidized Employment Expenditures |
Quarter 1 |
Quarter 2 |
Quarter 3 |
Quarter 4 |
FY 2008 |
Unadjusted Expenditures |
|
||||
Total Adjustments |
|
||||
Adjusted Expenditures |
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)
Contact in the Jurisdiction
OMB Control No: 0970-0366 Expiration Date: 10/31/2015