CCDF Submission of the Case-Level Report (ACF-801) |
ACF - 801 Child Care Quarterly Case Record Form (Printable version in Word) |
Head of Family Receiving Assistance |
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| 1. Reporting Period |
Month: _ _ |
Year: _ _ _ _ |
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| 2. Unique State Identifier (required in absence of SSN#) | _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ | ||
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3. Social Security Number (optional) |
_ _ _- _ _ - _ _ _ _ | ||
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4. FIPS Codes |
State: _ _ |
County: _ _ _ |
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5. Single Parent |
_ | ||
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6. Reason for Receiving Care |
_ | ||
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7. Total Monthly Child Care Co-payment by Family |
$ _, _ _ _ |
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8. Month/Year Child Care Assistance to the Family Started |
Month: _ _ |
Year: _ _ _ _ |
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9. Total Monthly Family Income for Determining Eligibility |
$ _ _ ,_ _ _ |
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Family Income Sources |
(Y/N) | ||
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10. Employment Including Self-Employment |
_ | ||
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11. Cash or Other Assistance Under Title IV of the Social Security Act (TANF) |
_ | ||
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12. State Program for Which State Spending Is Counted Towards Temporary Assistance to Needy Families MOE |
_ | ||
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13. Housing Voucher or Cash Assistance |
_ | ||
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14. Assistance Under the Food Stamps Act of 1977 |
_ | ||
| 15. Other Federal Cash Income Programs (such as SSI) | _ | ||
Head of Family Receiving Assistance |
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16. Number in Eligible Family (Required as of 04/ 01/ 02) |
_ | ||
Dependent Children Receiving Child Care Assistance |
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| Child Receiving Care | 17. Social Security Number (0ptional) OR Unique State Identifier (Required in absence of SSN#) |
18. Hispanic or Latino |
19. American Indian or Alaskan Native |
20. Asian |
21.
Black or African American |
22.
Native Hawaiian or Other Pacific Islander |
23. White |
24. Gender |
25. Month/Year of Birth |
26.
Type of Child Care |
27. Total Monthly Amount Paid to Provider |
28. Total Hours of Care Provided in Month |
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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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Child 1 |
_ _ _-_ _- _ _ _ _ | _ | _ | _ | _ | _ | _ | _ | _ _/_ _ _ _ | ||||
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Child 1, Provider 1 |
_ _ | $ _, _ _ _ | _ _ _ | ||||||||||
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Child 1, Provider 2 |
_ _ | $ _, _ _ _ | _ _ _ | ||||||||||
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Child 2 |
_ _ _-_ _- _ _ _ _ | _ | _ | _ | _ | _ | _ | _ | _ _/_ _ _ _ | ||||
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Child 2, Provider 1 |
_ _ | $ _, _ _ _ | _ _ _ | ||||||||||
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Child 2, Provider 2
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_ _ | $ _, _ _ _ | _ _ _ | ||||||||||
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Child 3 |
_ _ - _- _ _ _ _ | _ | _ | _ | _ | _ | _ | _ | _ / _ _ _ | ||||
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Child 3, Provider 1 |
_ _ | $ _, _ _ _ | _ _ _ | ||||||||||
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Child 3, Provider 2 |
_ _ | $ _, _ _ _ | _ _ _ | ||||||||||
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Child 4 |
_ _ - _- _ _ _ _ | _ | _ | _ | _ | _ | _ | _ | _ / _ _ _ | ||||
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Child 4, Provider 1 |
_ _ | $ _, _ _ _ | _ _ _ | ||||||||||
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Child 4, Provider 2 |
_ _ | $ _, _ _ _ | _ _ _ | ||||||||||