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
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
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
State total _______________
(if entry is greater than zero (0), attach a separate list in the following format.)
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
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
State total _______________
(if entry is greater than zero (0), attach a separate list in the following format.)
Children Aged 5-17 in FAMILIES RECEIVING PAYMENTS IN EXCESS OF $1,766.67
A. by COUNTY B. by LOCAL EDUCATIONAL AGENCY (LEA)
County name FIPS County Code Number LEA name LEA Code Number
2
Number of children ages 5 - 17, inclusive in foster homes
and in families above poverty receiving assistance under TANF
STATE: ________________________
October 2008 October 2007 October 2008 October 2007
Number of Number of Number of Children Ages 5-17 Number of Children Ages 5-17
State LEA Name of Children Ages 5-17 Children Ages 5-17 in Families Above Poverty in Families Above Poverty
State Code Code Local Educational Agency (LEA) in Foster Homes in Foster Homes Receiving TANF Payments Receiving TANF Payments
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
STATE TOTAL 0 0 0 0
3
Number of children ages 5 - 17, inclusive in foster homes
and in families above poverty receiving assistance under TANF
STATE: _________________________
October 2008
October 2008 Number of Children
Number of Ages 5-17
State County Name of Children Ages 5-17 in Families Above Poverty
State Code Code County in Foster Homes Receiving TANF Payments
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
STATE TOTAL 0 0