DEPARTMENT
OF HEALTH AND HUMAN SERVICES |
OMB Approval No.: 0970-0004 |
Administration
for Children and Families |
Expires: 11/30/2008 |
Form
ACF-4125 |
DESTROY PRIOR EDITIONS |
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ANNUAL STATISTICAL REPORT ON |
CHILDREN IN FOSTER HOMES AND CHILDREN IN FAMILIES
RECEIVING PAYMENTS |
IN EXCESS OF THE POVERTY INCOME LEVEL |
FROM A STATE PROGRAM FUNDED UNDER PART A OF |
TITLE IV OF THE SOCIAL SECURITY ACT |
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State __________________________________ |
State Agency
___________________________ |
Report for the month of October
2008 |
Prepared by: |
Name
__________________________________________________ |
Title
___________________________________________________ |
Signature_______________________________________________ |
Compiled by: |
Name
__________________________________________________ |
Phone #
________________________________________________ |
Email
address____________________________________________ |
Part I. |
NUMBER OF CHILDREN AGED 5-17 IN FOSTER HOMES |
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State total _______________ |
(if entry is greater than zero (0), attach a
separate list in the following
format.) |
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Children Aged 5-17 in Foster Homes |
A. by COUNTY |
B. by LOCAL EDUCATIONAL AGENCY (LEA) |
County
name FIPS County Code Number |
LEA name LEA Code (Agency
ID) Number |
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Part II. |
NUMBER OF CHILDREN AGED 5-17 IN FAMILIES RECEIVING
PAYMENTS IN EXCESS OF |
THE AMOUNT SPECIFIED FOR THIS REPORT PERIOD FROM A
STATE PROGRAM FUNDED UNDER |
PART A OF TITLE IV OF THE SOCIAL SECURITY ACT |
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State total _______________ |
(if entry is greater than zero (0), attach a
separate list in the following
format.) |
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Children Aged 5-17 in FAMILIES RECEIVING PAYMENTS
IN EXCESS OF $1,766.67
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A. by COUNTY |
B. by LOCAL EDUCATIONAL AGENCY (LEA) |
County
name FIPS County Code Number |
LEA name LEA Code Number |
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