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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 "Link to ACL" or "Link to ACIN" after the form version.  ACLs and ACINs providing further instructions or clarifications, can be found on the web at: www.cdss.ca.gov/lettersnotices/default.htm

 

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 Contact Information for Automated Report Form
CalFresh (Formerly FOOD STAMPS)
DFA 256 Food Stamp Program Participation and Benefit Issuance Report
  • 11/03 form version, in use beginning November 2003 report month. Link to ACL   
Link to 11/03
Form & Instructions
Contact Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
DFA 296 CalFresh Program Monthly Caseload Movement Statistical Report
  • 1/12 form version, in use beginning January 2012 report month.   Link to ACL
  • 1/99 form version, in use from January 1999 through December 2011 report months.   Link to ACL
Link to 1/12
Form & Instructions


Link to 1/99 
Form & Instructions
Contact Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
DFA 296X CalFresh Expedited Service Quarterly Statistical Report
  • 7/13 form version, in use beginning July - September 2013 report quarter.   Link to ACL
  • 10/04 form version, in use from October - December 2004 through April - June 2013 report quarters. Link to ACL
Link to 7/13
Form & Instructions

Link to 10/04
Form & Instructions

Contact Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
DFA 358F CalFresh Participants by Race/Ethnicity - Federal-Only and Combined Households
  • 7/14 form version, in use beginning July 2014 report month.   Link to ACIN
  • 7/13 form version, in use for July 2013 report month.   Link to ACIN
  • 7/12 form version, in use for July 2012 report month.   Link to ACIN
  • 7/11 form version, in use for July 2011 report month.   Link to ACIN  
Link to 7/14 Form & Instructions

Link to 7/13
Form & Instructions
 
 
Link to 7/12
Form & Instructions

Link to 7/11
Form & Instructions
Contact Tracy Ahlenstorf for automated form at DSSDB (916) 653-1322

Link to 7/13
Form


Link to 7/12
Form


Link to 7/11
Form
DFA 358S CalFresh Participants by Race/Ethnicity - State-Only Households
  • 7/14 form version, in use beginning July 2014 report month.   Link to ACIN
  • 7/13 form version, in use for July 2013 report month.  Link to ACIN
  • 7/12 form version, in use for July 2012 report month. Link to ACIN
  • 7/11 form version, in use for July 2011 report month. Link to ACIN
Link to 7/14 Form & Instructions

Link to 7/13
Form & Instructions


Link to 7/12
Form & Instructions


Link to 7/11
Form & Instructions

Contact Tracy Ahlenstorf for automated form at DSSDB (916) 653-1322

Link to 7/13
Form


Link to 7/12
Form


Link to 7/11
Form
STAT 47 Food Stamp Program Work Registrant, Able-Bodied Adults Without Dependents (ABAWD), and Food Stamp Employment and Training (FSET) Program Caseload Report
  • 4/06 form version, in use beginning April-June 2006 report quarter. Link to ACL

Link to 4/06
Form & Instructions
Contact Sunit Mayall for automated report form at DSSDB (916) 657-1642
STAT 48 STAT 48 Annual Work Registrant and Food Stamp Employment and Training (FSET) Program Caseload Report. 
  • 10/06 form version, in use beginning October 1, 2006 report period. Link to ACL

Link to 10/06
Form & Instructions 

Contact Sunit Mayall for automated report form at DSSDB (916) 657-1642
CalWORKs
CA 237 CW CalWORKs Cash Grant Caseload Movement Report
  • 4/14 form version, in use beginning April 2014 report month.  Link to ACL
  • 7/12 form version, in use from July 2012 through March 2014 report months. Link to ACL
  • 12/02 form version, in use from December 2002 through June 2012 report months.  Link to ACL
Link to 4/14 Form & Instructions

Link to 7/12
Form & Instructions

Link to 12/02
Form & Instructions
Contact Alice Connors for automated report form at DSSDB (916) 653-1338
CA 237 HA CalWORKs Homeless Assistance Program Monthly Statistical Report
  • 2/02 form version, in use beginning February 2002 report month.  Link to ACL

Link to 
Form & Instructions

Contact Roland Fong for automated report form at DSSDB (916) 653-1349
CA 253 CW CalWORKs Report on Reasons for Discontinuances of Cash Grant
  • 4/14 form version, in use beginning April 2014 report month.  Link to ACL 
  • 5/04 form version, in use from May 2004 through March 2014 report months.  Link to ACL
Link to 4/14 Form & Instructions

Link to 05/04
Form & Instructions

Contact Alice Connors for automated report form at DSSDB (916) 653-1338
CA 255 CW CalWORKs Report on Reasons for Denials and Other Non-Approvals of Applications for Cash Grant
  • 4/14 form version, in use beginning April 2014 report month.  Link to ACL 
  • 12/02 form version, in use from December 2002 through March 2014 report months.  Link to ACL
Link to 4/14 Form & Instructions

Link to 12/02
Form & Instructions
Contact Alice Connors for automated report form at DSSDB (916) 653-1338
CW 115 Child Care Monthly Report – CalWORKs Families
  • 10/06 form version, in use from October 2006 through June 2011 report months and resuming July 2012 report month.  Link to ACL   Link to ACIN
  • 7/11 form version, in use from July 2011 through June 2012 report months during the FY 11-12 Cal-Learn suspension period.   Link to ACIN    
Link to 10/06
Form & Instructions

Link to 7/11 Form & Instructions
Contact Danish Tariq for automated report form at DSSDB (916) 653-1339
CW 115A Child Care Monthly Report – Two-Parent Families
  • 10/06 form version, in use from October 2006 through June 2011 report months and resuming July 2012 report month.  Link to ACL   Link to ACIN
  • 7/11 form version, in use from July 2011 through June 2012 report months during the FY 11-12 Cal-Learn suspension period.   Link to ACIN     
Link to 10/06
Form & Instructions

Link to 7/11 Form & Instructions 
Contact Danish Tariq for automated report form at DSSDB (916) 653-1339
STAT 45 Cal-Learn Program Teen Parent Monthly Status Report

  • 6/14 form version, in use beginning June 2014 report month.  Link to ACL
  • 4/13 form version, in use from April 2013 through May 2014 report month.  Link to ACL
  • 7/11 form version, in use from July 2011 through June 2012 report months during the FY11-12 Cal-Learn suspension period.  This version continued to be used from July 2012 through March 2013 while counties re-implemented the Cal-Learn Program.   Link to ACL
  • 1/02 form version, in use from January 2002 through June 2011 report months.  Link to ACL

Link to 6/14 Form & Instructions


Link to 4/13 Form & Instructions



Link to 7/11 Form & Instructions


Link to 1/02 
Form & Instructions
Contact Danish Tariq for automated report form at DSSDB (916) 653-1339
WTW 25 CalWORKs Welfare-to-Work Monthly Activity Report - All (Other) Families
  • 10/06 form version, in use beginning October 2006 report month.   Link to ACL

Link to 10/06
Form & Instructions

Contact Roland Fong for automated report form at DSSDB (916) 653-1349
WTW 25A CalWORKs Welfare-to-Work Monthly Activity Report - Two-Parent Families
  • 10/06 form version, in use beginning October 2006 report month.   Link to ACL   

Link to 10/06
Form & Instructions 

Contact Roland Fong for automated report form at DSSDB (916) 653-1349
CHILDREN'S PROGRAMS
AD 202B Intercountry Adoption Program Quarterly Statistical Report
  • 1/13 form version, in use beginning January - March 2013 report quarter. Link to ACL
Link to
Form & Instructions
Contact Ertug Misirli for automated form at DSSDB (916) 657-1631
AD 42I Independent Adoption Program – Individual Case Report Link to
Form & Instructions

No automated form is available as PDF file is fillable 

Contact Ertug Misirli at DSSDB (916) 657-1631
AD 42R Agency Adoption Program – Individual Case Report Link to
Form & Instructions

No automated form is available as PDF file is fillable

Contact Ertug Misirli at DSSDB (916) 657-1631
AD 56A Agency Adoption Program Quarterly Statistical Report
  • 10/01 form version, in use beginning October - December 2001 report quarter.
Link to
Form & Instructions
Contact Ertug Misirli at DSSDB (916) 657-1631
AD 56D Independent Adoption Program and Adoption Set-Asides Quarterly Statistical Report
  • 1/02 form version, in use beginning January - March 2002 report quarter.

Link to
Form & Instructions

Contact Ertug Misirli for automated form at DSSDB (916) 657-1631
CA 237 EA Title IV-A Emergency Assistance (EA) Program Caseload Report
  • 7/02 form version, in use beginning July 2002 report month. Link to ACL
Link to
Form & Instructions
Contact Candace Dunham for automated report form at DSSDB (916) 653-1360
CA 237 FC Aid to Families with Dependent Children (AFDC) Foster Care (FC) Caseload Movement and Expenditures Report
  • 7/09 form version, in use beginning July 2009 report month.  Link to ACL
  • 3/06 form version, in use from March 2006 through June 2009 report months.   Link to ACL   

Link to 7/09 Form & Instructions

Link to 3/06
Form & Instructions 
7/09 Form:  Contact Adriana Neves for automated report form at DSSDB (916) 653-1309

Link to 3/06
Form
CA 237 KG Kinship Guardianship Assistance Payment Program (Kin-GAP) Caseload Movement Report
  • 1/02 form version, in use beginning January 2002 report month.  Link to ACL
Link to
Form & Instructions
Contact Danish Tariq for automated report form at DSSDB (916) 653-1339
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.  Link to ACL
Link to
Form & Instructions
Contact Danish Tariq for automated report form at DSSDB (916) 653-1339
FC 19 Intensive Treatment Foster Care Program Quarterly Statistical Report
  • 7/12 form version, in use beginning July-September 2012 report quarter.   Link to ACL    
Link to 7/12
Form & Instructions
Contact Adriana Neves for automated report form at DSSDB (916) 653-1309
FC 19A Multi-Dimensional Treatment Foster Care (MTFC) Program Quarterly Statistical Report
  • 7/12 form version, in use beginning July-September 2012 report quarter. Link to ACL
Link to 7/12
Form & Instructions
Contact Adriana Neves for automated report form at DSSDB (916) 653-1309
FC 23 Probation Foster Care Placement Monthly Caseload Statistical Report

The FC 23 report has been discontinued.  December 2013 is the last report month. Link to ACL

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

Link to Form & Instructions

Contact Adriana Neves for automated report form at DSSDB (916) 653-1309
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.  Link to ACL
  • 1/09 form version, in use from January-March 2009 through October-December 2013 report quarters.  Link to ACL
Link to 1/14 Form & Instructions

Link to 1/09 Form & Instructions  
Contact Ertug Misirli for automated report form at DSSDB (916) 657-1631
SOC 405A
/SOC 405A.1
Independent Living Program (ILP) Annual Statistical Report (SOC 405A)/
Independent Living Program (ILP) Annual Statistical Report for ILP Eligible Probation and Aftercare Youth (SOC 405A.1)
  • Oct12 (SOC 405A.1) form version, regarding October 1, 2012 through September 30, 2013 report period.

    All County Letter is in progress to discontinue this report.  The ACL will instruct counties that the report is being discontinued and counties are not to complete the October 1, 2012 through September 30, 2013 report.

  • Oct11 (SOC 405A.1) form version, in use October 1, 2011 through September 30, 2012 report period. 
  • 10/09 (SOC 405A.1) form version, in use from October 1, 2009 through September 30, 2010 report period.  Also in use from October 1, 2010 through September 30, 2011 report period.  Note:  No ACL or ACIN was issued for the October 2009 through September 2010 report period or the October 2010 through September 2011 report period.  An email reminder was sent instead.
  • 10/08 (SOC 405A.1) form version, in use from October 1, 2008 through September 30, 2009 report period.   Link to ACL
  • 10/08 (SOC 405A)  form version, in use from October 1, 2007 through September 30, 2008 report period.   Link to ACIN
Link to Oct11 SOC405A.1 Form & Instructions (PDF)

Link to 10/09 SOC 405A.1 Form & Instructions (PDF)

Link to 10/08 SOC 405A.1 Form & Instructions (PDF)

Link to 10/08
Form & Instructions





Contact Adriana Neves for automated report form at DSSDB (916) 653-1309




Link to 10/08
Form


SOC 405E Exit Outcomes for Youth Aging Out of Foster Care Quarterly Statistical Report
  • 7/08 form version, in use beginning July-September 2008 report quarter.  Link to ACL
Link to Form & Instructions Contact Adriana Neves for automated report form at DSSDB (916) 653-1309
COMMUNITY CARE LICENSING
LIC 181 Licensing of Facilities for Children Monthly Statistical Report
  • 12/01 form version, in use beginning December 2001 report month.  Link to ACL
Link to
Form & Instructions
Contact Adriana Neves for automated report form at DSSDB (916) 653-1309
DISABILITY AND ADULT PROGRAMS
ABD 216 Adult Programs Monthly Statistical Report
  • 11/92 form version, in use beginning December 1992 report month.  Link to ACL
Link to
Form & Instructions
Contact Candace Dunham for automated report form at DSSDB (916) 653-1360
CA 1037 Cash Assistance Program for Immigrants Monthly Caseload Movement Statistical Report
  • 1/00 form version, in use beginning October 1999 report month.  Link to ACL
Link to
Form & Instructions
Contact Sunit Mayall for automated report form at DSSDB (916) 657-1642
GR 237 General Relief and Interim Assistance to Applicants for SSI/SSP Monthly Caseload and Expenditure Statistical Report   Link to ACIN Link to
Form & Instructions
Contact Adriana Neves for automated report form at DSSDB (916) 653-1309
SOC 242 Adult Protective Services and County Services Block Grant Monthly Statistical Report
  • 10/14 form version, in use beginning October 2014 report month.    Link to ACL  
  • 4/07 form version, in use from April 2007 through September 2014 report month.   Link to ACL   

Link to 10/14 Form & Instructions

Link to 4/07
Form & Instructions 

Contact Candace Dunham for automated report form at DSSDB (916) 653-1360
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.  Link to ACL
Link to
Form & Instructions
Contact Danish Tariq for automated report form at DSSDB (916) 653-1339
FRAUD
CA 812 Quarterly Report of Overpayments and Collections – CalWORKs
  • 7/03 form version, in use beginning July - September 2003 report quarter.  Link to ACL

Link to
Form & Instructions

Contact Katie Girimonte for automated report form at DSSDB (916) 653-1363
DPA 266 Fraud Investigation Activity Report
  • 7/04 form version, in use beginning July 2004 report month.   Link to ACL

Link to
Form & Instructions

Contact Katie Girimonte for automated report form at DSSDB (916) 653-1363
DPA 482 IEVS Management Report
  • 10/01 form version, in use beginning October - December 2001 report quarter.   Link to ACL
Link to
Form & Instructions
Contact Katie Girimonte for automated report form at DSSDB (916) 653-1363
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
  • 7/14 form version, in use for July 2014 report month.  Link to ACIN
  • 7/13 form version, in use for July 2013 report month.    Link to ACIN
  • 7/12 form version, in use for July 2012 report month.
Link to 7/14 Form & Instructions

Link to 7/13
Form & Instructions

Link to 7/12
Form & Instructions
Contact Ertug Misirli for automated form at DDSDB (916) 657-1631

Link to 7/12
Form