Temporary Assistance For Needy Families Form (Page 4 of 4) in pdf

Temporary Assistance For Needy Families Form Page 4

Section Threee

Information for the Compilation of the Annual Report on State

Maintenance-of-Effort Programs: Form ACF-204

State Agency___________________________ For the Quarter

Beginning ______________ and Ending __________________.

Date Submitted ___________________

Contact Information: Name _________________________________

Email Address: ____________________________________________

Telephone:

________________________________________________

1. Name of Service Program

2. Total Number of Families Served under the program with MOE

Funds: (Indicate by program/purpose type.)

To reduce the incidence of out-of-wedlock

pregnancy________________________

To encourage the formation and maintenance of two-parent

families___________________________

This total number represents (check one):

_________ The total served during the fiscal quarter represented

by this report.

_________ The total served during the federal fiscal year (October

1, 2006-September 30, 2007.)

CERTIFICATION

SIGNATURE: ___________________________________________

NAME: _________________________________________________

TITLE: __________________________________________________

Temporary Assistance For Needy Families Form Page 4