Form ACF-202 Case Load Reduction Form Part I

Form ACF-202 – TANF Caseload Reduction Report

Date of Completion ________________________
State: ____________________________	Fiscal Year to which credit applies: ______
Overall Report ___ Two-parent Report ___ (check one)	Apply the overall credit to the two-parent ____ yes participation rate? ____ no
PART 1 –Eligibility Changes Made Since FY 2015 (Complete this section for EACH change)
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change (attach supporting materials to this form):
Estimated average monthly impact of this eligibility change on caseload in comparison year: _______
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change: (attach supporting materials to this form)
Estimated average monthly impact of this eligibility change on caseload in comparison year:
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change: (attach supporting materials to this form)
Estimated average monthly impact of this eligibility change on caseload in comparison year:
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change: (attach supporting materials to this form)
Estimated average monthly impact of this eligibility change on caseload in comparison year:
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change: (attach supporting materials to this form)
Estimated average monthly impact of this eligibility change on caseload in comparison year:
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change: (attach supporting materials to this form)
Estimated average monthly impact of this eligibility change on caseload in comparison year:
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change: (attach supporting materials to this form)
Estimated average monthly impact of this eligibility change on caseload in comparison year:
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change: (attach supporting materials to this form)
Estimated average monthly impact of this eligibility change on caseload in comparison year:
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change: (attach supporting materials to this form)
Estimated average monthly impact of this eligibility change on caseload in comparison year:
Name of eligibility change:
Implementation date of eligibility change:
Description of policy, including the change from prior policy:
Description of the methodology used to calculate the estimated impact of this eligibility change: (attach supporting materials to this form)
Estimated average monthly impact of this eligibility change on caseload in comparison year:

Date of Completion ________________________
State: ____________________________	Fiscal Year to which credit applies: ______

PART 2 – Estimate of Caseload Reduction Credit

(Complete Part 2 using Excel Workbook provided.)

Date of Completion ________________________
State: ____________________________	Fiscal Year to which credit applies: ______

PART 3 -- Certification

I certify that we have provided the public an appropriate opportunity to comment on the estimates and methodology used to complete this report and considered those comments in completing it. Further, I certify that this report incorporates all reductions in the caseload resulting from State eligibility changes and changes in Federal requirements since Fiscal Year 2015.

___________________________________________________________

(signature)

___________________________________________________________

(name)

___________________________________________________________

(title)

OMB Control No.: 0970-0338 Expiration Date: XX/XX/XXXX

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