Child Care Bureau: Laws, Policies, Program Instructions, and Allocations

CCDF Submission of the Case-Level Report (ACF-801)

Index: ACYF-PI-CC-98-01 | ACF-801 Form | ACF-801 Instructions | Sampling Specifications | (Collection also available in Word and PDF)

Family Income Sources				(Y/N)
ACF - 801 Child Care Quarterly Case Record Form			OMB #: 0970-0167 Expires: 11-30-2000
Head of Family Receiving Assistance
Reporting Period	Month: _ _	Year: _ _ _ _
Unique State Identifier (Optional)	_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Social Security Number	_ _ _- _ _ - _ _ _ _
FIPS Codes	State: _ _	County: _ _ _
Single Parent	_
Reason for Receiving Care	_
Total Monthly Child Care Copayment by Family	$ _, _ _ _
Month/Year Child Care Assistance to the Family Started	Month: _ _	Year: _ _ _ _
Total Monthly Family Income for Determining Eligibility	$ _ _, _ _ _
10. Employment Including Self-Employment				_
11. Cash or Other Assistance Under Title IV of the Social Security Act (TANF)				_
12. State Program for Which State Spending Is Counted Towards Temporary Assistance to Needy Families MOE				_
13. Housing Voucher or Cash Assistance				_
14. Assistance Under the Food Stamps Act of 1977				_
15. Other Federal Cash Income Programs (such as SSI)				_

Child Receiving Care	16. *Social Security Number (0ptional)*	17. Hispanic or Latino	18. American Indian or Alaskan Native	19. Asian	20. Black or African American	21. Native Hawaiian or Other Pacific Islander	22. White	23. Gender	24. Month/Year of Birth	25. Type of Child Care	26. Total Monthly Amount Paid to Provider	27. Total Hours of Care Provided in Month
Dependent Children Receiving Child Care Assistance									OMB #: 0970-0167 Date: 11-30-2000
Child 1	_ _ _-_ _- _ _ _ _	_	_	_	_	_	_	_	_ _/_ _ _ _	-
Child 1, Provider 1	-									_ _	$ _, _ _ _	_ _ _
Child 1, Provider 2	-									_ _	$ _, _ _ _	_ _ _
Child 2	_ _ _-_ _- _ _ _ _	_	_	_	_	_	_	_	_ _/_ _ _ _	-
Child 2, Provider 1	-									_ _	$ _, _ _ _	_ _ _
Child 2, Provider 2	-									_ _	$ _, _ _ _	_ _ _
Child 3	_ _ _-_ _- _ _ _ _	_	_	_	_	_	_	_	_ _/_ _ _ _	-
Child 3, Provider 1	-									_ _	$ _, _ _ _	_ _ _
Child 3, Provider 2	-									_ _	$ _, _ _ _	_ _ _
Child 4	_ _ _-_ _- _ _ _ _	_	_	_	_	_	_	_	_ _/_ _ _ _	-
Child 4, Provider 1	-									_ _	$ _, _ _ _	_ _ _
Child 4, Provider 2	-									_ _	$ _, _ _ _	_ _ _
Child 5	_ _ _-_ _- _ _ _ _	_	_	_	_	_	_	_	_ _/_ _ _ _	-
Child 5, Provider 1	-									_ _	$ _, _ _ _	_ _ _
Child 5, Provider 2	-									_ _	$ _, _ _ _	_ _ _

Index: ACYF-PI-CC-98-01 | ACF-801 Form | ACF-801 Instructions | Sampling Specifications | (Collection also available in Word and PDF)