ACF-801 On-Line Help
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ACF - 801 Child Care Quarterly Case Record Form OMB #: 0970-0167 Expires: 05-31-2009 |
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Head of Family Receiving Assistance |
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| 1. Reporting Period | Month/Year | |||
| 2. Unique State Identifier (required in absence of SSN#) |  |
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| 3. Social Security Number (optional) | ||||
| 4. FIPS Codes | ||||
| 5. Single Parent | ||||
| 6. Reason for Receiving Care | ||||
| 7. Total Monthly Child Care Co-payment by Family | ||||
| 8. Month/Year Child Care Assistance to the Family Started | ||||
| 9. Total Monthly Family Income for Determining Eligibility | ||||
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 TANF MOE |
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13. Housing Voucher or Cash Assistance |
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14. Assistance Under the Food Stamps Act of 1977 |
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| 15. Other Federal Cash Income Programs (such as SSI) | ||||
| 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) |
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Child 1 | ||||||||||||
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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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 |
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