ACF-700 with revisions marked

CHILD CARE AND DEVELOPMENT FUND ANNUAL REPORT

OMB Control Number: 0980-0241

ON SERVICES PROVIDED FROM OCTOBER 1, 20__ THROUGH SEPTEMBER 30, 20__

Expiration Date: TBD

COMPLETE NAME OF TRIBAL LEAD AGENCY:

CATEGORY/TYPE OF CHILD CARE

CARE PROVIDED BY

CARE PROVIDED BY CCDF PROVIDER--

ADDRESS:

A CCDF PROVIDER--NO LICENSE CATEGORY AVAILABLE

LICENSED OR REGULATED

IN A

IN A

CHILD'S HOME BY A

FAMILY HOME BY A

GROUP HOME BY A

CONTACT PERSON:

(A)

(B)

(C)

(D)

(E)

(F)

(G)

(H)

(I)

(J)

(K)

(L)

Phone: E-Mail:

TOTAL

Relative

Non-Relative

Relative

Non-Relative

Relative

Non-Relative

Center

Child's Home

Family Home

Group Home

Center

1. Total number of families that received child care services this fiscal year

2 a. Average number of children served each month

2 b. Total number of children that received services this fiscal year

3. Total number of children receiving services that fall

into each age category:

a. 0 up to 1 year

a.

a.

a.

a.

a.

a.

a.

a.

a.

a.

a.

a.

b. 1 year up to 2 years

b.

b.

b.

b.

b.

b.

b.

b.

b.

b.

b.

b.

c. 2 years up to 3 years

c.

c.

c.

c.

c.

c.

c.

c.

c.

c.

c.

c.

d. 3 years up to 4 years

d.

d.

d.

d.

d.

d.

d,

d.

d.

d.

d.

d.

e. 4 years up to 5 years

e.

e.

e.

e.

e.

e.

e.

e.

e.

e.

e.

e.

f. 5 years up to 6 years

f.

f.

f.

f.

f.

f.

f.

f.

f.

f.

f.

f.

g. 6 years up to 13 years

g.

g.

g.

g.

g.

g.

g.

g.

g.

g.

g.

g.

h. Total number of children 0 to 13 years (add Column A, 3a thru 3g)

h.

h.

0

h.

0

h.

0

h.

0

h.

0

h.

0

h.

0

h.

0

h.

0

h.

0

h.

0

i. 13 - and older

i.

i.

i.

i.

i.

i.

i.

i.

i.

i.

i.

i.

4. Number of children who received child care services

Because:

a. Their parent(s) worked

a.

b. Their parent(s) were in training or an education program

b.

c. Child received or needed protective services

c.

Because there was a Federal Emergency and:

d. Their parent(s) worked

d.

e. Their parent(s) were in training or an education program

e.

f. Child received or needed protective services

f.

5. Average number of hours of child care service provided

per child per month

6. Average monthly amount paid for child care service

a. Average monthly CCDF program subsidy per child

a.

a.

a.

a.

a.

a.

a.

a.

a.

a.

a.

a.

b. Average monthly parent copayment per child

b.

b.

b.

b.

b.

b.

b.

b.

b.

b.

b.

b.

7. Number of children served whose family income was:

a. at or below the poverty threshold for families of the same size

a.

]

b. above the poverty threshold but at or below 150 percent of the poverty threshold for families of the same size

b.

c. above 150 percent of the poverty threshold but at or below 200 percent of the poverty threshold for families of the same size

c.

d. above 200 percent of the poverty threshold for families of the same size

d.

8. Number of children served by payment type this fiscal year:

a. Grant/contract with provider

a.

a.

a.

a.

a.

a.

a.

a.

a.

a.

a.

a.

b. Certificate or voucher to parent and/or provider

b.

b.

b.

b.

b.

b.

b.

b.

b.

b.

b.

b.

c. Cash payment to parent

c.

c.

c.

c.

c.

c.

c.

c.

c.

c.

c.

c.

d. Tribally-operated center

d.

d.

d.

d.

d.

d.

d.

d.

d.

d.

d.

d.

Comments: (Please use the back of this sheet if necessary)

Public reporting burden for this collection of information is estimated to average 38 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.