Form 196R ACF-196R Form

Department of Health and Human Services
Administration for Children and Families

Temporary Assistance for Needy Families (TANF) ACF - 196R Financial Report
Part 1: Expenditure Data
State

Grant Year

Fiscal Year

Report Quarter Ending

Next Quarter Ending

Report is Submitted as:
[ ] New [ ] Revised
-------------------------------[ ] Final
(Zero Grant Funds Remaining)

State Funds

Federal Funds

Federal Funds
Contingency Funds

State Family Assistance
Grant

Aw ard Reconciliation
Federal Share at FMAP Rate of:
______%

(A)

1. Awarded
2. Transferred to CCDF Discretionary
3. Transferred to SSBG
4. Adjusted Award
5. Carryover

(B)

(C)

Federal Funds
Emergency Contingency
Funds
(Authorized by ARRA)

(D)
$

(E)

0%

$
$

Expenditures Categories

FEDERAL EXPENDITURES

6 Basic Assistance
6.a. Basic Assistance (excluding Relative Foster Care Maintenance Payments and
Adoption and Guardianship Subsidies)
6.b. Relative Foster Care Maintenance Payments and Adoption and Guardianship
Subsidies
7. Assistance Authorized Solely Under Prior Law
7.a. Foster Care Payments
7.b. Juvenile Justice Payments
7.c. EmergencyAssistance Authorized Solely Under Prior Law
8. Non-Assistance Authorized Solely Under Prior Law
8.a. Child Welfare or Foster Care Services
8.b. Juvenile Justice Services
8.c. Emergency Services Authorized Solely Under Prior Law
9. Work, Education, and Training Activities
9.a. Subsidized Employment
9.b. Education and Training
9.c. Additional Work Activities
10. Work Supports
11. Early Care and Education
11.a. Child Care (Assistance and Non-Assistance)
11.b. Pre-Kindergarten/Head Start
12. Financial Education and Asset Development
13. Refundable Earned Income Tax Credits
14. Non-EITC Refundable State Tax Credits
15. Non-Recurrent Short Term Benefits
16. Supportive Services
17. Services for Children and Youth
18. Prevention of Out-of-Wedlock Pregnancies
19. Fatherhood and Two-Parent Family Formation and Maintenance Programs
20. Child Welfare Services
20.a. Family Support/ Family Preservation /Reunification Services
20.b. Adoption Services
20.c. Additional Child Welfare Services
21. Home Visiting Programs
22. Program Management
22.a. Administrative Costs
22.b. Assessment/Service Provision
22.c. Systems
23.Other
24.Total Expenditures

MOE EXPENDITURES
SEPARATE STATE
PROGRAMS

STATE MOE EXPENDITURES
IN TANF

EXPENDITURES WITH
EMERGENCY
CONTINGENCY FUNDS

EXPENDITURES WITH
CONTINGENCY FUNDS

$

$

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25 Transitional Services for Employed
26 Job Access

$

$

$

$

$

$

$

$

27. Federal Unliquidated Obligations
28. Unobligated Balance
29. State Replacement Funds

$

$

$

$

$

$
$

Quarterly Estimate

Estimate TANF Federal Funds

30. Estimate of TANF Funds Requested for the Following Quarter

$

THIS IS TO CERTIFY THAT THE INFORMATION REPORTED ON ALL PARTS OF THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

SIGNATURE: AUTHORIZED STATE OFFICIAL
DATE SUBMITTED:
PAGE 1 OF 2 of APPROVED OMB No: 0970-0446, Expiration Date XX/XX/XXXX

TYPED NAME, TITLE, AGENCY NAME

Department of Health and Human Services
Administration for Children and Families

Temporary Assistance for Needy Families (TANF) ACF - 196R Financial Report
Part 2: Narrative Section
State

Expenditure Categories

Fiscal Year

Descriptions of Expenditures

Methodology Used to Estimate Federal Funding and

State MOE Expenditures

6 Basic Assistance
6.a. Basic Assistance (excluding Relative Foster Care Maintenance Payments and
Adoption and Guardianship Subsidies)
6.b. Relative Foster Care Maintenance Payments and Adoption and Guardianship
Subsidies
7. Assistance Authorized Solely Under Prior Law
7.a. Foster Care Payments
7.b. Juvenile Justice Payments
7.c. EmergencyAssistance Authorized Solely Under Prior Law
8. Non-Assistance Authorized Solely Under Prior Law
8.a. Child Welfare or Foster Care Services
8.b. Juvenile Justice Services
8.c. Emergency Services Authorized Solely Under Prior Law
9. Work, Education, and Training Activities
9.a. Subsidized Employment
9.b. Education and Training
9.c. Additional Work Activities
10. Work Supports
11. Early Care and Education
11.a. Child Care (Assistance and Non-Assistance)
11.b. Pre-Kindergarten/Head Start
12. Financial Education and Asset Development
13. Refundable Earned Income Tax Credits
14. Non-EITC Refundable State Tax Credits
15. Non-Recurrent Short Term Benefits
16. Supportive Services
17. Services for Children and Youth
18. Prevention of Out-of-Wedlock Pregnancies
19. Fatherhood and Two-Parent Family Formation and Maintenance Programs
20. Child Welfare Services
20.a. Family Support/ Family Preservation /Reunification Services
20.b. Adoption Services
20.c. Additional Child Welfare Services
21. Home Visiting Programs
22. Program Management
22.a. Administrative Costs
22.b. Assessment/Service Provision
22.c. Systems
23.Other
THIS IS TO CERTIFY THAT THE INFORMATION REPORTED ON ALL PARTS OF THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

SIGNATURE: AUTHORIZED STATE OFFICIAL
DATE SUBMITTED:
PAGE 2 OF 2 of APPROVED OMB No: 0970-0446, Expiration Date XX/XX/XXXX

TYPED NAME, TITLE, AGENCY NAME