ACF-801 Form
ACF-801 Child Care Quarterly Case Record Form
| Head of Family Receiving Assistance | |||
| 1. Reporting Period | Month: _ _ | Year: _ _ _ _ | |
| 2. Unique State Identifier (required in absence of SSN#) | _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ | ||
| 3. Social Security Number (optional) | _ _ _ - _ _ - _ _ _ _ | ||
| 4. FIPS Codes | State: _ _ | County: _ _ _ | |
| 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 | Month: _ _ | Year: _ _ _ _ | |
| 9. Total Monthly Family Income for Determining Eligibility | $ _ _ , _ _ _ | ||
| Family Income Sources | (Yes/No) | ||
| 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 TANF 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) | _ | ||
| 16. Number in Eligible Family (Required as of 04/ 01/ 02) | _ _ | ||
| Dependent Children Receiving Child Care Assistance | |||||||||||||
| 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 |
|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | _ _ | $ _, _ _ _ | _ _ _ | ||||||||||