Reports Forms and Instructions

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Index of Data Table Reports - Forms and Instructions

BLANK FORMS AND INSTRUCTONS: The forms and instructions available below are the approved versions. They are available here for ease of reference and use. The PDF files cannot be completed online. To view or print a read-only PDF copy of the blank form and instructions for a Data Table Report prepared by CDSS Data Systems and Survey Design Bureau (DSSDB), please click on the link box for the report needed. A Data Table Report’s form and instructions are to be used for specific report periods, as indicated in the All County Letter or All County Information Notice. Before selecting a link to print a form and instructions, please review the “bullets” listed for the report to determine the version of the form and instructions needed for the report period you are reviewing. The form and instructions for the most current report period is the first bullet listed, and the bullet is bolded.

ACLs/ACINs: The All County Letters (ACLs) / All County Information Notices (ACINs) which implemented the forms and instructions that have been developed or revised , can be found by clicking on either "ACL" or "ACIN" after the form version. ACLs and ACINs provide further instructions or clarifications.

Report Number Report Name
  • Form's version date and review periods covered,
    with the current version listed first and in bold.
Link to Blank Form and Form’s Instructions in PDF Report Contact Information
CalFresh (Formerly FOOD STAMPS)
CF 296 CalFresh Monthly Caseload Movement Statistical Report (formerly DFA 296 and DFA 296X reports)

  • 7/16 form version, in use beginning July 2016 report month. ACIN I-19-16   ACL 16-39  ACL 16-39E  ACL 16-39E2

    Effective July 2016 report month the CF 296 replaces the DFA 296 and DFA 296X.
  • 7/16 Form & Instructions

    Jacquelyn Alvarez           
    (916) 653-1340
    admcf296@dss.ca.gov

    DFA 256 Food Stamp Program Participation and Benefit Issuance Report
    • 11/03 form version, in use beginning November 2003 report month. ACL
    11/03 Form & Instructions

    Jacquelyn Alvarez  
    (916) 653-1340  
    admdfa256@dss.ca.gov

    DFA 296 CalFresh Program Monthly Caseload Movement Statistical Report   

    Effective July 2016 report month the CF 296 replaces the DFA 296. ACIN I-19-16 ACL 16-39

    • 1/12 form version, in use from January 2012 through June 2016 report months. ACL
    1/12 Form & Instructions

    Jacquelyn Alvarez  
    (916) 653-1340      
    admdfa296@dss.ca.gov

    DFA 296X CalFresh Expedited Service Quarterly Statistical Report   

    Effective July 2016 report month the CF 296 replaces the DFA 296X. ACIN I-19-16   ACL 16-39

    • 7/13 form version, in use beginning July - September 2013 report quarter. ACL
    • 10/04 form version, in use from October - December 2004 through April - June 2013 report quarters. ACL
    7/13 Form & Instructions

    10/04 Form & Instructions

    Jacquelyn Alvarez 
    (916) 653-1340  
    admdfa296x@dss.ca.gov

    DFA 358F CalFresh Participants by Race/Ethnicity - Federal-Only and Combined Households
    • 7/17 form version, in use for July 2017 report month.  ACIN
    • 7/16 form version, in use for July 2016 report month.  ACIN 
    • 7/15 form version, in use for July 2015 report month.  ACIN

    7/17 Form & Instructions

    7/16 Form & Instructions

    7/15 Form & Instructions

     

    Jacquelyn Alvarez  
    (916) 653-1340  
    admdfa358f@dss.ca.gov

    DFA 358S CalFresh Participants by Race/Ethnicity - State-Only Households
    • 7/17 form version, in use for July 2017 report month. ACIN
    • 7/16 form version, in use for July 2016 report month. ACIN 
    • 7/15 form version, in use for July 2015 report month.  ACIN
    •   

    7/17 Form & Instructions

    7/16 Form & Instructions

    7/15 Form & Instructions




    Jacquelyn Alvarez  
    (916) 653-1340
    admdfa358@dss.ca.gov

      

    STAT 47 Non-Assistance CalFresh Work Registrants, Able-Bodied Adults Without Dependents ((ABAWD), and Employment and Training (E&T) Program Quarterly Statistical Report
    (Formerly Food Stamp Program Work Registrant, Able-Bodied Adults Without Dependents (ABAWD), and Food Stamp Employment and Training (FSET) Program Caseload Report)
    • 10/14 form version, in use beginning October - December 2014 report quarter. ACL
    • 4/06 form version, in use from April-June 2006 through July-September 2014 report quarters. ACL
    10/14 Form & Instructions

    4/06 Form & Instructions

    Sunit Mayall  
    (916) 657-1642  
    admstat47@dss.ca.gov

    STAT 48 STAT 48 Annual Work Registrant and Food Stamp Employment and Training (FSET) Program Caseload Report.
    • 10/06 form version, in use from October 1, 2006 through October 1, 2013 report periods. ACL

    This report is discontinued. The last report is October 1, 2013. Use this form version for revisions for October 1, 2006 through October 1, 2013.


    10/06 Form & Instructions

    Sunit Mayall   
    (916) 657-1642  

    WINS 2 Work Incentive Nutritional Supplement (WINS) Monthly Caseload Report
    • 10/14 form version, in use beginning October 2014 report period. ACL

    10/14 Form & Instructions

    Sunit Mayall  
    (916) 657-1642  
    admwins2@dss.ca.gov

    CalWORKs
    CA 237 CW CalWORKs Cash Grant Caseload Movement Report
    • 4/15 form version, in use beginning April 2015 report month.   ACL
    • 4/14 form version, in use from April 2014 through March 2015 report months. ACL
    • 7/12 form version, in use from July 2012 through March 2014 report months. ACL
    • 12/02 form version, in use from December 2002 through June 2012 report months. ACL
    4/15 Form & Instructions

    4/14 Form & Instructions


    7/12 Form & Instructions

    12/02 Form & Instructions

    Rachael Gastelum   
    (916) 653-1309  
    DSSDB@dss.ca.gov

    CA 237 HA CalWORKs Homeless Assistance Program Monthly Statistical Report
    • 2/02 form version, in use beginning February 2002 report month. ACL

    2/02 Form & Instructions

    Jenn Greaves  
    (916) 653-1349   
    admca237ha@dss.ca.gov

    CA 253 CW CalWORKs Report on Reasons for Discontinuances of Cash Grant
    • 4/15 form version, in use beginning April 2015 report month.   ACL
    • 4/14 form version, in use from April 2014 through March 2015 report months. ACL
    • 5/04 form version, in use from May 2004 through March 2014 report months. ACL
    4/15 Form & Instructions

    4/14 Form & Instructions


    5/04 Form & Instructions

    Rachael Gastelum  
    (916) 653-1309  
    DSSDB@dss.ca.gov

    CA 255 CW CalWORKs Report on Reasons for Denials and Other Non-Approvals of Applications for Cash Grant
    • 4/15 form version, in use beginning April 2015 report month.   ACL
    • 4/14 form version, in use from April 2014 through March 2015 report months. ACL
    • 12/02 form version, in use from December 2002 through March 2014 report months. ACL
    4/15 Form & Instructions

    4/14 Form & Instructions

    12/02 Form & Instructions

    Rachael Gastelum  
    (916) 653-1309  
    DSSDB@dss.ca.gov

    CW 115 Child Care Monthly Report – CalWORKs Families
    • 7/15 form version, in use beginning July 2015 report month.   ACL
    • 10/06 form version, in use from October 2006 through June 2011 report months and resuming July 2012 through June 2015 report months. ACL / ACIN

    7/15 Form & Instructions

    10/06 Form & Instructions

    Jilzy Christensen  
    (916) 653-1354  
    admcw115@dss.ca.gov

    CW 115A Child Care Monthly Report – Two-Parent Families
    • 7/15 form version, in use beginning July 2015 report month.   ACL
    • 10/06 form version, in use from October 2006 through June 2011 report months and resuming July 2012 through June 2015 report months.   ACL / ACIN

    7/15 Form & Instructions

    10/06 Form & Instructions

    Jilzy Christensen   
    (916) 653-1354  
    admcw115@dss.ca.gov

    FSP 14 CalWORKs Family Stabilization (FS) Program
    • 7/14 form version, in use beginning July - September 2014 report quarter. ACL
    7/14 Form & Instructions

    Jilzy Christensen   
    (916) 653-1354  
    admfsp14@dss.ca.gov

    HSP 14 CalWORKs Housing Support Program (HSP)
    9/14 Form & Instructions

    Jenn Greaves  
    (916) 653-1349  
    admhsp14@dss.ca.gov

    STAT 45 Cal-Learn Program Teen Parent Monthly Status Report

    • 6/14 form version, in use beginning June 2014 report month. ACL
    • 4/13 form version, in use from April 2013 through May 2014 report month. ACL

    6/14 Form & Instructions

    4/13 Form & Instructions

    Jilzy Christensen   
    (916) 653-1354  
    admstat45@dss.ca.gov

    WTW 25 CalWORKs Welfare-to-Work Monthly Activity Report - All (Other) Families
    • 10/06 form version, in use beginning October 2006 report month. ACL

    10/06 Form & Instructions

    Jenn Greaves  
    (916) 653-1349  
    admwtw25@dss.ca.gov

    WTW 25A CalWORKs Welfare-to-Work Monthly Activity Report - Two-Parent Families
    • 10/06 form version, in use beginning October 2006 report month. ACL

    10/06 Form & Instructions

    Jenn Greaves  
    (916) 653-1349
    admwtw25a@dss.ca.gov

    CHILDREN'S PROGRAMS
    AD 202B Intercountry Adoption Program Quarterly Statistical Report
    • 1/13 form version, in use beginning January - March 2013 report quarter. ACL
    1/13 Form & Instructions

    Nathan Morris 
    (916) 651-0284
    admad202b@dss.ca.gov

    AD 42I Independent Adoption Program – Individual Case Report Form & Instructions

    No automated form is available as PDF file is fillable 

    Nathan Morris 
    (916) 651-0284   

    AD 42R Agency Adoption Program – Individual Case Report Form & Instructions

    No automated form is available as PDF file is fillable 

    Nathan Morris 
    (916) 651-0284 

    AD 56A Agency Adoption Program Quarterly Statistical Report
    • 4/16 form version, in use beginning April - June 2016 report quarter.

    Note: The 4/16 form, instructions and validations have minor text and formatting changes only: no changes to the data cells or data definitions/instructions have been made.

    • 10/01 form version, in use from October - December 2001 through January - March 2016 report quarter.
    4/16 Form & Instructions

    10/01 Form & Instructions

    Nathan Morris 
    (916) 651-0284  
    admad56a@dss.ca.gov

    AD 56D Independent Adoption Program and Adoption Set-Asides Quarterly Statistical Report
    • 1/02 form version, in use beginning January - March 2002 report quarter.

    1/02 Form & Instructions

    Nathan Morris 
    (916) 651-0284
    admad56d@dss.ca.gov

    CA 237 EA Title IV-A Emergency Assistance (EA) Program Caseload Report
    • 7/02 form version, in use beginning July 2002 report month. ACL
    7/02 Form & Instructions

    Evangeline (Gigi) Sabile  
    (858) 755-7291  
    admca237ea@dss.ca.gov

    CA 237 FC Aid to Families with Dependent Children (AFDC) Foster Care (FC) Caseload Movement and Expenditures Report
    • 12/17 form version, in use beginning December 2017 report month. ACL
    • 7/09 form version, in use from July 2009 through November 2017 report months. ACL

    12/17 Form & Instructions

    7/09 Form & Instructions

    Tracy Ahlenstorf  
    (916) 653-1322 admca237fc@dss.ca.gov

    CA 237 KG Kinship Guardianship Assistance Payment Program (Kin-GAP) Caseload Movement Report
    • 1/02 form version, in use beginning January 2002 report month. ACL
    1/02 Form & Instructions

    Evangeline (Gigi) Sabile  
    (858) 755-7291
    admca237kg@dss.ca.gov

    CA 237 KG-F Kinship Guardianship Assistance Payment (Kin-GAP) Program Caseload Movement Report - Federal Only
    • 1/11 form version, in use beginning January 2011 report month. ACL
    1/11 Form & Instructions

    Evangeline (Gigi) Sabile  
    (858) 755-7291  
    adma237kgf@dss.ca.gov

    FC 19 Intensive Treatment Foster Care Program Quarterly Statistical Report
    • 7/12 form version, in use beginning July-September 2012 report quarter. ACL
    7/12 Form & Instructions

    Katie Girimonte   
    (916) 653-1363  
    admfc19@dss.ca.gov

    FC 19A Multi-Dimensional Treatment Foster Care (MTFC) Program Quarterly Statistical Report
    • 7/12 form version, in use beginning July-September 2012 report quarter. ACL
    7/12 Form & Instructions

    Katie Girimonte   
    (916) 653-1363  
    admfc19a@dss.ca.gov

    FC 23 Probation Foster Care Placement Monthly Caseload Statistical Report

    The FC 23 report was discontinued effective January 1, 2014. December 2013 is the last report month. ACL

    • 1/05 form version, in use from January 2005 through December 2013 report months. ACL

    1/05 Form & Instructions

    DSSDB
    (916) 651-8269
    FC-AAP-KG 84 Supplement to the Rate Requests for Dual Agency AFDC-FC, AAP and KG Children Quarterly Statistical Report
    • 1/14 form version, in use beginning January-March 2014 report quarter. ACL
    • 1/09 form version, in use from January-March 2009 through October-December 2013 report quarters. ACL
    1/14 Form & Instructions

    1/09 Form & Instructions

    Tracy Ahlenstorf  
    (916) 653-1322  
    admfcaap84@dss.ca.gov

    LIC 181   Licensing of Facilities for Children Monthly Statistical Report
    • 01/17 form version, in use beginning January 2017 report month. ACL
    • 12/01 form version, in use from December 2001 through December 2016 report months. ACL

    01/17 Form & Instructions      

    12/01 Form & Instructions 
           

    Katie Girimonte   
    (916) 653-1363  
    admlic181@dss.ca.gov

    SOC 405X Outcomes for Nonminor Dependents Child Welfare Youth Exiting Foster Care Quarterly Statistical Report
    • 4/15 form version, in use beginning April-June 2015 report quarter.  ACL
    4/15 Form & Instructions

    Tracy Ahlenstorf  
    (916) 653-1322  
    admsoc405x@dss.ca.gov

    SOC 405XP Outcomes for Nonminor Dependents Probation Foster Youth Exiting Foster Care Quarterly Statistical Report
    • 4/15 form version, in use beginning April-June 2015 report quarter.  ACL
    4/15 Form & Instructions

    Tracy Ahlenstorf  
    (916) 653-1322  
    admsoc405xp@dss.ca.gov

    DISABILITY AND ADULT PROGRAMS
    ABD 216 Adult Programs Monthly Statistical Report
    • 11/92 form version, in use beginning December 1992 report month. ACL
    11/92 Form & Instructions

    Evangeline (Gigi) Sabile  
    (858) 755-7291 
    admabd216@dss.ca.gov

    CA 1037 Cash Assistance Program for Immigrants Monthly Caseload Movement Statistical Report
    • 1/00 form version, in use beginning October 1999 report month. ACL
    1/00 Form & Instructions

    Katie Girimonte  
    (916) 653-1363  
    admca1037@dss.ca.gov

    GR 237 General Relief and Interim Assistance to Applicants for SSI/SSP Monthly Caseload and Expenditure Statistical Report ACIN Form & Instructions

    Katie Girimonte  
    (916) 653-1363  
    admgr237@dss.ca.gov

    SOC 242 Adult Protective Services and County Services Block Grant Monthly Statistical Report
    • 9/15 form version, in use beginning September 2015 report month. ACIN
    • 10/14 form version, in use beginning January 2015 report month. ACL / ACIN
    • 4/07 form version, in use from April 2007 through December 2014 report month. ACL

    9/15 Form & Instructions

    10/14 Form & Instructions

    4/07 Form & Instructions

    Tracy Ahlenstorf  
    (916) 653-1322  
    admsoc242@dss.ca.gov

    SOC 808 Quarterly Report of Overpayments and Collections for the Cash Assistance Program for Immigrants (CAPI)
    • 7/02 form version, in use beginning July - September 2002 report quarter. ACL
    7/02 Form & Instructions

    Katie Girimonte  
    (916) 653-1363  
    admsoc808@dss.ca.gov

    FRAUD
    CA 812 Quarterly Report of Overpayments and Collections – CalWORKs
    • 7/03 form version, in use beginning July - September 2003 report quarter. ACL

    7/03 Form & Instructions

    Eli Tuisku  
    (916) 653-1339  
    admca812@dss.ca.gov

    DPA 266 Fraud Investigation Activity Report
    • 7/04 form version, in use beginning July 2004 report month. ACL

    7/04 Form & Instructions

    Eli Tuisku  
    (916) 653-1339  
    admdpa266@dss.ca.gov

    DPA 482 IEVS Management Report
    • 10/01 form version, in use beginning October - December 2001 report quarter. ACL
    10/01 Form & Instructions

    Eli Tuisku   
    (916) 653-1339  
    admdpa482@dss.ca.gov

    IMMIGRATION SERVICES 
    IS-DACA Immigration Services Deferred Action for Childhood Arrivals (DACA) Application Assistance Quarterly Report
        
    • (1/17) This form version is in use from January – March 2017 through October through December 2017 report quarters (FY 16-17, Contract 2, Four Quarters).

    1/17 Form & Instructions 

    Eli Tuisku  
    (916) 653-1339
    admisdaca@dss.ca.gov 

    IS-EO  Immigration Services Education and Outreach Quarterly Report  
        
    • (1/17) This form version is in use from January – March 2017 through October through December 2017 report quarters (FY 16-17, Contract 2, Four Quarters).
    1/17 Form & Instructions
      

    Eli Tuisku  
    (916) 653-1339
    admiseo@dss.ca.gov 

    IS-LTTA Immigration Services Legal Training and Technical Assistance Quarterly Report
       
    • (1/17) This form version is in use from January – March 2017 through October through December 2017 report quarters (FY 16-17, Contract 2, Four Quarters).
    1/17 Form & Instructions

    Eli Tuisku  
    (916) 653-1339  
    admisltta@dss.ca.gov

    IS-NAT

    Immigration Services Naturalization Application Assistance Quarterly Report

    • (1/17) This form version is in use from January – March 2017 through October through December 2017 report quarters (FY 16-17, Contract 2, Four Quarters).
    1/17 Form & Instructions

    Eli Tuisku  
    (916) 653-1339
    admisnat@dss.ca.gov           

    IS-OIR Immigration Services Other Immigration Remedies Application Assistance Quarterly Report

    • (1/17) This form version is in use from January – March 2017 through October through December 2017 report quarters (FY 16-17, Contract 2, Four Quarters).
    1/17 Form & Instructions

    Eli Tuisku  
    (916) 653-1339  
    admisoir@dss.ca.gov

    MULTIPLE PROGRAMS
    ABCD 350 Annual Recipient Report on CalWORKs, Foster Care, Social Services, Non-Assistance CalFresh, CalWORKs Welfare-to-Work, Refugee Cash Assistance, and the Cash Assistance Program for Immigrants Ethnic Origin and Primary Language
    • 7/17 form version, in use for July 2017 report month. ACIN
    • 7/16 form version, in use for July 2016 report month. ACIN
    • 7/15 form version, in use for July 2015 report month.  ACIN  

    7/17 Form & Instructions

    7/16 Form & Instructions

    7/15 Form & Instructions


     

    Sunit Mayall  
    (916) 657-1642  
    admabcd350@dss.ca.gov