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Instructions For Form Acf-4125 - 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 Page 2

Report only the children who reside within the State and report the children by LEA in which they reside. If the

LEA of residence is not known, the LEA of school attendance may be used. If the LEA of residence changes

during the month of October, the last known location should be used.

Please ensure that the sum of the data reported on attached pages is equal to the State total shown on the form.

Part II.

Report, by LEA, the number of children aged 5-17 (inclusive) in families which, during the month of October

2016, had a cash assistance payment in excess of the amount specified for this report period. If data are not

available by LEA, report by county. (The "amount specified" is based on poverty income guidelines for a

family of four and will be provided annually to the States by the Administration for Children and Families via

Program Instruction or other appropriate means.)

If no family received an assistance payment exceeding the amount specified, enter zero. Do not include under

this part children in foster care or those in institutions for neglected or delinquent children. Include cash

assistance only; non-monetary assistance and services, vendor payments of all kinds, and income from any

other sources should be excluded. Consider multiple cases in the same dwelling as separate families.

Please assure that the sum of the data reported on attached pages is equal to the State total shown on the form.

SUBMITTAL PROCEDURE

Please submit this report to the addresses given below. Also, please send a copy to the appropriate HHS/ACF

Regional Office.

Please include on the front page the contact information (the name, telephone number and email address) of the

person who compiled the report.

If you have questions or need further information, please contact:

Paulette M. Bowen,

ACF/OFA/Division of Data Collection and Analysis:

Phone: 202/401-9251

FAX: 202/401-5554

FAX: 202/205-5887

E-mail:

paulette.bowen@acf.hhs.gov

Mail:

Mary E. Switzer Building

Suite #3404B

Washington DC 20201

Instructions For Form Acf-4125 - 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 Page 2

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