Data Verification Procedures; Caseload Reduction Documentation Process; Reasonable Cause/Corrective Compliance Documentation Process, TANF Data Report; SSP-MOE Data Report

TANF DATA REPORT - SECTION 2
TANF DISAGGREGATED DATA COLLECTION FOR FAMILIES NO LONGER RECEIVING ASSISTANCE UNDER
THE TANF PROGRAM

GENERAL INFORMATION
1.

State FIPS
Code

2.

County FIPS Code

3.

Tribal Code
(For Tribal Use Only)

4.

Reporting Month
5.

Year

Y

Stratum

Month

Y

Y

Y

M

M

FAMILY LEVEL DATA
6.

Case Number - TANF

7.

ZIP Code

8.

Disposition

9.

Reason for
Closure

ASSISTANCE RECEIVED BY THE FAMILY
10.

Received Subsidized Housing

11.

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

Received Medical Assistance

12.

Received Food Stamps

TANF DATA REPORT - SECTION 2

13.

Received Subsidized
Child Care

Page 1

PERSON LEVEL DATA
14.
Person

Family
Affiliation

15.
Y

Date of Birth (Age)
Y

Y

Y

M

16.
M

D

Social Security Number

D

1

-

-

2

-

-

3

-

-

4

-

-

5

-

-

6

-

-

7

-

-

8

-

-

9

-

-

10

-

-

11

-

-

12

-

-

13

-

-

14

-

-

15

-

-

16

-

-

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 2

Page 2

17. Race/Ethnicity

Person

A.

Ethnicity

Race

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

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 2

Page 3

Person

18.

Gender

19.

Received Disability Benefits

A.

Received Federal
Disability Insurance
Benefits - OASDI

B.

Received Benefits
Based on Federal
Disability Status

E.
C.

Received Aid Under
Title XIV-APDT

D.

Received Aid Under
Title XVI-AABD

Received Aid
Under Title
XVI-SSI

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 2

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22.
21.
Person

20.

Marital Status

Relationship to Head
of Household

Parent with
Minor Child in
Family

23.

Needs of a
Pregnant
Woman

24.

Educational Level

25.

Citizenship / Alienage

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 2

Page 5

26.
Person

Number of Months Countable
Toward Federal Time Limit

27.

Number of Countable Months Remaining
Under State's (Tribe's) Time Limit

28.

Employment Status

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 2

Page 6

AMOUNT OF INCOME, BY TYPE
Person

29.

Amount Earned Income

30.

Amount of Unearned Income

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

OMB Number 0970-0199 - Expiration Date: 06/30/2002
ACF - 199

TANF DATA REPORT - SECTION 2

Page 7