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Reports Forms and Instructions

The reports on this site are in Adobe Portable Document Format (PDF). Click here to download the free Adobe Acrobat that you need to read and print these reports.

Index of Data Table Reports - Forms and Instructions

BLANK FORMS AND INSTRUCTONS: The forms and instructions available below are the approved versions. They are available here for ease of reference and use. The PDF file can be printed and then completed by hand or typewriter. The PDF files cannot be completed online. To view or print a read-only PDF copy of the blank form and instructions for a Data Table Report prepared by CDSS Data Systems and Survey Design Bureau (DSSDB), please click on the link box for the report needed. a Data Table Report’s form and instructions are to be used for specific report periods, as indicated in the All County Letter or All County Information Notice. Before selecting a link to print a form and instructions, please review the “bullets” listed for the report to determine the version of the form and instructions needed for the report period you are completing or revising. The form and instructions for the most current report period is the first bullet listed, and the bullet is bolded.

We are in the process of placing the forms in Excel format on this page. Files that are listed as "Pending" in the last column "Link to Blank Form in Excel" will be added soon.

ACLs/ACINs: The All County Letters (ACLs) which implemented the forms and instructions that have been developed or revised since 1997 , and the ACLs and All County Information Notices (ACINs) providing further instructions or clarifications, can be found on the web at: www.cdss.ca.gov/lettersnotices/default.htm

NEW LOCATION: DSSDB’s office location changed in June 2008. Not all the reports listed below may have the correct mailing address and fax number listed on its form and instructions. The correct address and fax number are as follows:

California Department of Social Services
Data Systems and Survey Design Bureau, M.S. 19-081
P.O. Box 944243
Sacramento, Ca 94244-2430
Fax: (916) 657-2074

Report Number Report Name
  • Form's version date and review periods covered,
    with the current version listed first and in bold.
Link to Blank Form and Form’s Instructions in PDF Link to Blank Form in Excel
CalWORKs
CA 237 CW CalWORKs Cash Grant Caseload Movement Report
  • 12/02 form version, in use beginning December 2002 report month.
Link to
Form & Instructions
Contact Clarice Baldwin for automated report form at DSSDB (916) 928-7605
CA 237 EA Title IV-a Emergency Assistance (EA) Program Caseload Report
  • 7/02 form version, in use beginning July 2002 report month.
Link to
Form & Instructions 		Link to 7/02
Form
CA 237 HA CalWORKs Homeless Assistance Program Monthly Statistical Report
  • 2/02 form version, in use beginning February 2002 report month.

Link to 
Form & Instructions
Contact Marina Guzman for automated report form at DSSDB (916) 928-7677
CA 253 CW CalWORKs Report on Reasons for Discontinuances of Cash Grant
  • 5/04 form version, in use beginning May 2004 report month.

Link to
Form & Instructions
Contact Clarice Baldwin for automated report form at DSSDB (916) 928-7605
CA 255 CW CalWORKs Report on Reasons for Denials and Other Non-Approvals of Applications for Cash Grant
  • 12/02 form version, in use beginning December 2002 report month.

Link to
Form & Instructions
Contact Clarice Baldwin for automated report form at DSSDB (916) 928-7605
CW 115 Child Care Monthly Report – CalWORKs Families
  • 10/06 form version, in use beginning October 2006 report month.
  • 1/03 form version, in use beginning January 2003 report month.
Link to 10/06
Form & Instructions

Link to 1/03
Form & Instructions
Contact Barbara Wood for automated report form at DSSDB (916) 928-7675
CW 115A Child Care Monthly Report – Two-Parent Families
  • 10/06 form version, in use beginning October 2006 report month.
  • 1/03 form version, in use beginning January 2003 report month.
Link to 10/06
Form & Instructions

Link to 1/03
Form & Instructions
Contact Barbara Wood for automated report form at DSSDB (916) 928-7675
STAT 45 Cal-Learn Program Teen Parent Monthly Status Report

  • 1/02 form version, in use beginning January 2002 report month.
Link to
Form & Instructions
Contact Marina Guzman for automated report form at DSSDB (916) 928-7677
WTW 25 CalWORKs Welfare-to-Work Monthly Activity Report - All (Other) Families
  • 10/06 form version, in use beginning October 2006 report month.
  • 1/03 form version, in use from January 2003 through September 2006 report months.

Link to 10/06
Form & Instructions

Link to 1/03
Form & Instructions
Contact Lynne Shearer for automated report form at DSSDB (916) 928-7655
WTW 25A CalWORKs Welfare-to-Work Monthly Activity Report - Two-Parent Families
  • 10/06 form version, in use beginning October 2006 report month.
  • 1/03 form version, in use from January 2003 through September 2006 report months.

Link to 10/06
Form & Instructions

Link to 1/03
Form & Instructions
Contact Lynne Shearer for automated report form at DSSDB (916) 928-7655
CHILDREN'S PROGRAMS
AD 42I Independent Adoption Program – Individual Case Report Link to
Form & Instructions
No Excel file is available as PDF file is fillable
AD 42R Agency Adoption Program – Individual Case Report Link to
Form & Instructions
No Excel file is available as PDF file is fillable
AD56A Agency Adoption Program Quarterly Statistical Report
  • 10/01 form version, in use beginning October - December 2001 report quarter.
Link to
Form & Instructions 		Pending
AD56D Independent Adoption Program and Adoption Set Asides Quarterly Statistical Report
  • 1/02 form version, in use beginning January - March 2002 report quarter.

Link to
Form & Instructions
Pending
AD202B Intercountry Adoption Program Quarterly Statistical Report
  • 1/02 form version, in use beginning January - March 2002 report quarter.
Link to
Form & Instructions
Pending
CA 237 FC Aid to Families with Dependent Children (AFDC) Foster Care (FC) Caseload Movement and Expenditures Report
  • 3/06 form version, in use beginning March 2006 report month.
  • 7/00 form version, in use from July 2000 through February 2006 report months.
Link to 3/06
Form & Instructions

Link to 7/00
Form & Instructions 		Link to 3/06
Form

Link to 7/00
Form
CA 237 KG Kinship Guardianship Assistance Payment Program (Kin-GAP) Caseload Movement Report
  • 1/02 form version, in use beginning January 2002 report month.

Link to
Form & Instructions 		Contact Marina Guzman for automated report form at DSSDB (916) 928-7677
FC 19 Intensive Treatment Foster Care Program Quarterly Statistical Report
  • 4/02 form version, in use beginning April-June 2002 report quarter.
Link to
Form & Instructions 		Contact Donna Howard for automated report form at DSSDB (916) 928-7610
FC 23 Probation Foster Care Placement Monthly Caseload Statistical Report
  • 1/05 form version, in use beginning January 2005 report month.

Link to Form & Instructions
Contact Barbara Wood for automated report form at DSSDB (916) 928-7675
SOC 405A Independent Living Program (ILP) Annual Statistical Report
  • 10/07 form version, in use from October 1, 2006 through September 30, 2007 report period.
  • 10/06 form version, in use from October 1, 2005 through September 30, 2006 report period.
  • 10/05 form version, in use from October 1, 2004 through September 30, 2005 report period.
Link to 10/07
Form & Instructions

Link to 10/06
Form & Instructions

Link to 10/05
Form & Instructions

Link to 10/07
Form

Link to 10/06
Form

Link to 10/05
Form

SOC 405E
Exit Outcomes for Youth Aging Out of Foster Care Quarterly Statistical Report
  • 7/08 form version, in use beginning July-September 2008 report quarter.
Link to Form & InstructionsPending
COMMUNITY CARE LICENSING
LIC 181 Licensing of Facilities for Children Monthly Statistical Report
  • 12/01 form version, in use beginning December 2001 report month.
Link to
Form & Instructions 		Contact Clarice Baldwin for automated report form at DSSDB (916) 928-7605
DISABILITY AND ADULT PROGRAMS
ABD 216 Adult Programs Monthly Statistical Report
  • 11/92 form version, in use beginning December 1992 report month.
Link to
Form & Instructions 		Contact Barbara Wood for automated report form at DSSDB (916) 928-7675
CA 1037 Cash Assistance Program for Immigrants Monthly Caseload Movement Statistical Report
  • 1/00 form version, in use beginning October 1999 report month.
Link to
Form & Instructions 		Contact Barbara Wood for automated report form at DSSDB (916) 928-7675
GR 237 General Relief and Interim Assistance to Applicants for SSI/SSP Monthly Caseload and Expenditure Statistical Report Link to
Form & Instructions 		Contact Clarice Baldwin for automated report form at DSSDB (916) 928-7605
SOC 242 Adult Protective Services and County Services Block Grant Monthly Statistical Report
  • 4/07 form version, in use beginning April 2007 report month.
  • 1/03 form version, in use from February 2003 through March 2007 report months.

Link to 4/07
Form & Instructions

Link to 1/03
Form & Instructions
Contact Barbara Wood for automated report form at DSSDB (916) 928-7675
SOC 808 Quarterly Report of Overpayments and Collections for the Cash Assistance Program for Immigrants (CAPI)
  • 7/02 form version, in use beginning July - September 2002 report quarter.
Link to
Form & Instructions
Contact Barbara Wood for automated report form at DSSDB (916) 928-7675
FOOD STAMPS
DFA 256 Food Stamp Program Participation and Benefit Issuance Report
  • 11/03 form version, in use beginning November 2003 report month.
  • 3/98 form version, in use beginning March 1998 report month.
Link to 11/03
Form & Instructions

Link to 3/98
Form & Instructions 		Contact Lynne Shearer for automated report form at DSSDB (916) 928-7655
DFA 296 Food Stamp Program Monthly Caseload Movement Statistical Report
  • 1/99 form version, in use beginning January 1999 report month.
Link to
Form & Instructions 		Contact Lynne Shearer for automated report form at DSSDB (916) 928-7655
DFA 296X Food Stamp Program Expedited Service Quarterly Statistical Report
  • 10/04 form version, in use beginning October - December 2004 report quarter.
  • 12/88 form version, in use from October - December 1988 report quarter through July - September 2004 report quarter.

Link to 10/04
Form & Instructions

Link to 12/88
Form & Instructions 		Pending
DFA 358F Food Stamp Program Participants by Ethnic Group
  • 7/08 form version, in use for July 2008 report month.
  • 7/07 form version, in use for July 2007 report month.
  • 7/06 form version, in use for July 2006 report month.
Link to 7/08
Form & Instructions

Link to 7/07
Form & Instructions

Link to 7/06
Form & Instructions

Link to 7/08
Form

Link to 7/07
Form

Link to 7/06
Form

DFA 358S Food Stamp Program Participants by Ethnic Group
  • 7/08 form version, in use for July 2008 report month.
  • 7/07 form version, in use for July 2007 report month.
  • 7/06 form version, in use for July 2006 report month.
Link to 7/08
Form & Instructions

Link to 7/07
Form & Instructions

Link to 7/06
Form & Instructions

Link to 7/08
Form

Link to 7/07
Form

Link to 7/06
Form

STAT 47 Food Stamp Program Work Registrant, Able-Bodied Adults Without Dependents (ABAWD), and Food Stamp Employment and Training (FSET) Program Caseload Report
  • 4/06 form version, in use beginning April-June 2006 report quarter.
  • 10/03 form version, in use October-December 2003 through January-March 2006 report quarters.

Link to 4/06
Form & Instructions

Link to 10/03
Form & Instructions
Contact Lynne Shearer for automated report form at DSSDB (916) 928-7655
STAT 48 STAT 48 Annual Work Registrant and Food Stamp Employment and Training (FSET) Program Caseload Report
  • 10/06 form version, in use beginning October 1, 2006 report period.
  • 10/03 form version, in use October 1, 2003 through October 1, 2005 report periods.

Link to 10/06
Form & Instructions

Link to 10/03
Form & Instructions
Contact Lynne Shearer for automated report form at DSSDB (916) 928-7655
FRAUD
CA 812 Quarterly Report of Overpayments and Collections – CalWORKs
  • 7/03 form version, in use beginning July - September 2003 report quarter.

Link to
Form & Instructions
Contact Sandy Hudgens for automated report form at DSSDB (916) 928-7678
DPA 266 Fraud Investigation Activity Report
  • 7/04 form version, in use beginning July 2004 report month.

Link to
Form & Instructions
Contact Sandy Hudgens for automated report form at DSSDB (916) 928-7678
DPA 482 IEVS Management Report
  • 10/01 form version, in use beginning October - December 2001 report quarter.
Link to
Form & Instructions 		Contact Sandy Hudgens for automated report form at DSSDB (916) 928-7678
MULTIPLE PROGRAMS
ABCD 350 Annual Recipient Report on CalWORKs, Foster Care, Social Services, Nonassistance Food Stamps, CalWORKs Welfare to Work, Refugee Cash Assistance, and the Cash Assistance Program for Immigrants Ethnic Origin and Primary Language
  • 7/08 form version, in use for July 2008 report month.
  • 7/07 form version, in use for July 2007 report month.
  • 7/06 form version, in use for July 2006 report month.
Link to 7/08
Forms & Instructions

Link to 7/07
Form & Instructions

Link to 7/06
Form & Instructions

Link to 7/08
Form

Link to 7/07
Form

Link to 7/06
Form