Form ACF-204 Annual Report on State MOE Programs

OMB #: 0970-0248

Expiration Date: XX/XX/20XX

Attachment A

General Instructions:

Each State must provide the information indicated below on its TANF program regardless of the funding source -- i.e., no matter whether the State used segregated Federal TANF funds, segregated State TANF funds, or commingled funds to pay for the benefit or service. If the State elects to report on other benefits or activities provided through other program funding streams, please mention it after the TANF-funded benefits or activities for each item.

1. The State's definition of each work activity.

Response:

2. A description of the transitional services provided to families no longer receiving assistance due to employment.

Response:

3. A description of how a State will reduce the amount of assistance payable to a family when an individual refuses to engage in work without good cause pursuant to 45 CFR 261.14 of this chapter.

Response:

4. The average monthly number of payments for child care services made by the State through the use of disregards, by the following types of child care providers:

1. Licensed/regulated in-home child care: 0

2. Licensed/regulated family child care: 0

3. Licensed/regulated group home child care: 0

4. Licensed/regulated center-based child care: 0

5. Legally operating (i.e., no license category available in State or locality) in- home child care provided by a non-relative: 0

6. Legally operating (i.e., no license category available in State or locality) in- home child care provided by a relative: 0

7. Legally operating (i.e., no license category available in State or locality) family child care provided by a non-relative: 0

8. Legally operating (i.e., no license category available in State or locality) family child care provided by a relative: 0

9. Legally operating (i.e., no license category available in State or locality) group child care provided by a non-relative: 0

10. Legally operating (i.e., no license category available in State or locality) group child care provided by a relative: 0

11. Legally operated (i.e., no license category available in State or locality) center- based child care. 0

5. If the State has adopted the Family Violence Option and wants Federal recognition of its good cause domestic violence waivers under 45 CFR 260.50-58, then provide (a) a description of the strategies and procedures in place to ensure that victims of domestic violence receive appropriate alternative services and (b) an aggregate figure for the total number of good cause domestic waivers granted.

Response:

6. A description of any nonrecurrent, short-term benefits (as defined in 45 CFR 260.31(b)(1)) provided, including:

i. The eligibility criteria associated with such benefits, including any restrictions on the amount, duration, or frequency of payments;

Response:

ii. Any policies that limit such payments to families that are eligible for TANF assistance or that have the effect of delaying or suspending a family's eligibility for assistance;

Response:

iii. Any procedures or activities developed under the TANF program to ensure that individuals diverted from assistance receive information about, referrals to, or access to other program benefits (such as Medicaid and the Supplemental Nutrition Assistance Program) that might help them make the transition from welfare to work.

Response:

7. A description of the grievance procedures the State has established and is maintaining to resolve displacement complaints, pursuant to section 407(f)(3) of the Social Security Act. This description must include the name of the State agency with the lead responsibility for administering this provision and explanations of how the State has notified the public about these procedures and how an individual can register a complaint.

Response:

8. A summary of State programs and activities directed at the third and fourth statutory purposes of TANF (as specified at 45 CFR 260.20(c) and (d) of this chapter).

a. Summarize below, the State programs and activities directed at preventing and reducing the incidence of out-of-wedlock pregnancies and establishing annual numerical goals for preventing and reducing the incidence of these pregnancies (TANF purpose 3):

Response:

b. Summarize below, the State programs and activities directed at encouraging the formation and maintenance of two-parent families (TANF purpose 4):

Response:

9. An estimate of the total number of individuals who have participated in subsidized employment under §261.30(b) or (c) of this chapter. 0

9. A description of EBT policies and practices in the following four areas: (1) procedures for preventing the use of TANF assistance via electronic benefit transfer transactions in any liquor store; any casino, gambling casino, or gaming establishment, and any retail establishment which provides adult oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment;(2) how the state identifies the locations specified in the statute;(3) procedures for ongoing monitoring to ensure policies are being carried out as intended; and (4)how the state plans to respond to findings of non-compliance or program ineffectiveness.

Response:

Attachment B

Grantee Information

State

Fiscal Year

Program Information

Provide the following information for EACH PROGRAM (according to the nature of the benefit or service provided) for which the State claims MOE expenditures. Complete and submit this report in accordance with the attached instructions.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)   Public reporting burden for this collection of information is estimated to average 118 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.

1. Name of Benefit or Service Program:

Response:

2. Description of the Major Program Benefits, Services, and Activities:

Response:

3. Purpose(s) of Benefit or Service Program:

Response:

4. Program Type. (Check one)

☐TANF ☐ State

5. Description of Work Activities (Complete only if this program is a separate State program):

Response:

6. Total State Expenditures for the Program for the Fiscal Year: $0

7. Total State MOE Expenditures under the Program for the Fiscal Year: $0

8. Total Number of Families Served under the Program with MOE Funds: 0

This last figure represents (Check one):

☐The average monthly total for the fiscal year. ☐The total served over the fiscal year.

9. Financial Eligibility Criteria for Receiving MOE-funded Program Benefits or Services:

Response:

10. Prior Program Authorization: Was this program authorized and allowable under prior law? (Check one)

☐Yes ☐No

11. Total Program Expenditures in FY 1995 (NOTE: Provide only if response on question 10 is No): $0

Certification

Certify:

This certifies that all families for which the State claims MOE expenditures for the fiscal year meet the State's criteria for "eligible families."
Signature
Name
Title
Date Submitted
Approved OMB No. 0970-0248 Form ACF-204, expires XX/XX/20XX.