TANF DATA REPORT - SECTION 1
TANF DISAGGREGATED DATA COLLECTION FOR FAMILIES RECEIVING ASSISTANCE UNDER
THE TANF PROGRAM


GENERAL INFORMATION

																	4.	Reporting Month
1.	State FIPS Code				2.	County FIPS Code				3.	Tribal Code (For Tribal Use Only)							Year					Month				5.	Stratum

																		Y	Y	Y	Y		M	M

FAMILY LEVEL DATA

6.	Case Number - TANF																7.	ZIP Code


	8.	Funding Stream				9.	Disposition				10.	New Applicant					11.	Number of Family Members					12.	Type of Family for Work Participation



ASSISTANCE RECEIVED BY THE FAMILY

13.	Receives Subsidized Housing				14.	Receives Medical Assistance				15.	Receives Food Stamps				16.	Amount of Food Stamps Assistance					17.	Receives Subsidized Child Care					18.	Amount of Subsidized Child Care


19.	Amount of Child Support						20.	Amount of the Family's Cash Resources



AMOUNT OF ASSISTANCE RECEIVED AND THE NUMBER OF MONTHS THAT THE FAMILY HAS RECEIVED EACH TYPE OF ASSISTANCE UNDER STATE (TRIBAL) TANF PROGRAM

21.	Cash and Cash Equivalent
A.	Amount							B.	Number of Months


22.	TANF Child Care																				23.	. Transportation
A.	Amount					B.	Number of Children Covered				C.	Number of Months										A.	Amount							B.	Number of Months


24.	Transitional Services																				25.	Other Assistance
	A.	Amount						B.	Number of Months													A.	Amount							B.	Number of Months



REASON FOR AND AMOUNT OF REDUCTION IN ASSISTANCE

26.	Reason and Amount of Reduction in Assistance
	A.	Sanctions:
	i.	Total Dollar Amount for Reduction Due to Sanctions				ii.	Work Requirements Sanction				iii.	Family Sanction for an Adult with No High School Diploma or Equivalent					iv.	Sanction for Teen Parent Not Attending School				v.	Non-cooperation with Child Support			vi.	Failure to Comply with an Individual Responsibility Plan				vii.	Other Sanction


	B.	Recoupment of Prior Overpayment							C.	Other
									i.	Total Dollar Amount of Reduction Due to Other Reasons								ii.	Family Cap			iii.	Reduction Based on Length of Receipt of Assistance					iv.	Other, Non-sanction


27.	Waiver Evaluation Research Group							28.	Is the TANF Family Exempt from Federal Time Limit Provisions														29.	Is the TANF Family a New Child-Only Family?



PERSON LEVEL DATA

ADULT AND MINOR CHILD HEAD-OF-HOUSEHOLD CHARACTERISTICS

Adult			30.	Family Affiliation			31.	Non-Custodial Parent Indicator			32.	Date of Birth (Age)								33.	Social Security Number
											Y	Y	Y	Y	M	M	D	D
	1																						-			-
	2																						-			-
	3																						-			-
	4																						-			-
	5																						-			-
	6																						-			-

			34.	Race/Ethnicity
			Ethnicity						Race
Adult			A.	Hispanic or Latino					B.	American Indian of Alaska Native				C.	Asian			D.	Black or African American				E.	Native Hawaiian or Pacific Islander				F.	White
	1
	2
	3
	4
	5
	6

							36.	Receives Disability Benefits
Adult			35.	Gender			A.	Receives Federal Disability Insurance Benefits - OASDI					B.	Receives Benefits Based on Federal Disability Status					C.	Receives Aid Under Title XIV-APDT				D.	Receives Aid Under Title XVI-AABD				E.	Receives Aid Under Title XVI-SSI
	1
	2
	3
	4
	5
	6

Adult			37.	Marital Status			38.	Relationship to Head of Household					39.	Parent with Minor Child in the Family					40.	Needs of a Pregnant Woman			41.	Educational Level				42.	Citizenship / Alienage
	1
	2
	3
	4
	5
	6

Adult			43.	Cooperation in Child Support			44.	Number of Months Countable Toward Federal Time Limit				45	Number of Countable Months Remaining Under State's (Tribe's) Time Limit					46.	Is Current Month Exempt From State's (Tribe's) Time Limit				47.	Employment Status			48.	Work-Eligible Individual Indicator			49.	Work Participation
	1
	2
	3
	4
	5
	6

ADULT WORK PARTICIPATION ACTIVITIES

Adult																			53.	Work Experience
			50.	Unsubsidized Employment				51.	Subsidized Private Sector Employment					52.	Subsidized Public Sector Employment				A.	Hours of Participation			B.	Excused Absences			C.	Holidays			54.	On-the-Job Training
	1
	2
	3
	4
	5
	6

Adult			55.	Job Search and Job Readiness Assistance														56.	Community Service Programs
			A.	Hours of Participation			B.	Excused Absences			C.	Holidays							A.	Hours of Participation			B.	Excused Absences			C.	Holidays
	1
	2
	3
	4
	5
	6

Adult			57.	Vocational Educational Training														58.	Job Skills Training Directly Related to Employment
			A.	Hours of Participation			B.	Excused Absences			C.	Holidays							A.	Hours of Participation			B.	Excused Absences			C.	Holidays
	1
	2
	3
	4
	5
	6


Adult			59.	Education Directly Related to Employment for Individuals with No High School Diploma or Certificate of High School Equivalency														60.	Satisfactory School Attendance for Individuals with No High School Diploma or Certificate of High School Equivalency
			A.	Hours of Participation			B.	Excused Absences			C.	Holidays							A.	Hours of Participation			B.	Excused Absences			C.	Holidays
	1
	2
	3
	4
	5
	6

Adult			61.	Providing Child Care Services to an Individual Who is Participating in a Community Service Program
			A.	Hours of Participation			B.	Excused Absences			C.	Holidays					62	Other Work Activities				63	Number of Deemed Core Hours for Overall Rate					64	Number of Deemed Core Hours for the Two-Parent Rate
	1
	2
	3
	4
	5
	6

AMOUNT OF INCOME, BY TYPE

														66.	Amount of Unearned Income
Adult					65.	Amount of Earned Income									A.	Earned Income Tax Credit - EITC										B.	Social Security
	1
	2
	3
	4
	5
	6


Adult					C.	SSI									D.	Worker's Compensation										E.	Other Unearned Income
	1
	2
	3
	4
	5
	6



CHILD CHARACTERISTICS

Child									68.	Date of Birth (Age)
			67.	Family Affiliation					Y	Y	Y	Y	M	M	D	D				69.	Social Security Number
	1																						-			-
	2																						-			-
	3																						-			-
	4																						-			-
	5																						-			-
	6																						-			-
	7																						-			-
	8																						-			-
	9																						-			-
	10																						-			-

			70.	Race/Ethnicity
			Ethnicity						Race
Child			A.	Hispanic or Latino					B.	American Indian or Alaska Native				C.	Asian			D.	Black or African American				E.	Native Hawaiian or Pacific Islander				F.	White
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10


							72.	Receives Disability Benefits:
Child			71.	Gender			A.	Receives Benefits Based on Federal Disability Status					B.	Receives Aid Under Title XVI-SSI					73.	Relationship to Head of Household				74.	Parent with Minor Child in the Family				75.	Educational Level
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10

Child											77.	Amount of Unearned Income
Child			76.	Citizenship / Alienage							A.	SSI					B.	Other Unearned Income
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10