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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 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)
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

Effective July 2016 report month the CF 296 replaces the DFA 296 and DFA 296X.

7/16 Form & Instructions Contact Jacquelyn Neri for automated report form at DSSDB (916) 653-1340
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 Contact Jacquelyn Neri for automated report form at DSSDB (916) 653-1340
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 Contact Jacquelyn Neri for automated report form at DSSDB (916) 653-1340
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

Contact Jacquelyn Neri for automated report form at DSSDB (916) 653-1340
DFA 358F CalFresh Participants by Race/Ethnicity - Federal-Only and Combined Households
  • 7/16 form version, in use for July 2016 report month.  ACIN 
  • 7/15 form version, in use for July 2015 report month.  ACIN
  • 7/14 form version, in use for July 2014 report month.   ACIN
  • 7/13 form version, in use for July 2013 report month. ACIN
7/16 Form & Instructions

7/15 Form & Instructions

7/14 Form & Instructions


7/13 Form & Instructions 
Contact Jacquelyn Neri for automated report form at DSSDB (916) 653-1340
DFA 358S CalFresh Participants by Race/Ethnicity - State-Only Households
  • 7/16 form version, in use for July 2016 report month. ACIN 
  • 7/15 form version, in use for July 2015 report month.  ACIN
  • 7/14 form version, in use for July 2014 report month. ACIN
  • 7/13 form version, in use for July 2013 report month. ACIN

 

7/16 Form & Instructions

7/15 Form & Instructions


7/14 Form & Instructions


7/13 Form & Instructions



Contact Jacquelyn Neri for automated report form at DSSDB (916) 653-1340

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
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 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

Contact Sunit Mayall for automated report form at DSSDB (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
Contact Sunit Mayall for automated report form at DSSDB (916) 657-1642
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
Contact Rachael Gastelum for automated report form at DSSDB (916) 653-1309
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
Contact Pamela Kian or Angela Vasquez for automated report form at DSSDB (916) 651-8269
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

Contact Rachael Gastelum for automated report form at DSSDB (916) 653-1309
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
Contact Rachael Gastelum for automated report form at DSSDB (916) 653-1309
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

Contact Jenna Montero for automated report form at DSSDB (916) 653-1354
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

Contact Jenna Montero for automated report form at DSSDB (916) 653-1354
FSP 14 CalWORKs Family Stabilization (FS) Program
  • 7/14 form version, in use beginning July - September 2014 report quarter. ACL
7/14 Form & Instructions
Contact Jenna Montero for automated report form at DSSDB (916) 653-1354
HSP 14 CalWORKs Housing Support Program (HSP)
9/14 Form & Instructions
 Contact Pamela Kian or Angela Vasquez for automated report form at DSSDB (916) 651-8269
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

Contact Jenna Montero for automated report form at DSSDB (916) 653-1354
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
Contact Pamela Kian or Angela Vasquez for automated report form at DSSDB (916) 651-8269
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
Contact Pamela Kian or Angela Vasquez for automated report form at DSSDB (916) 651-8269
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 Contact Candace Dunham for automated form at DSSDB (916) 653-1360
AD 42I Independent Adoption Program – Individual Case Report Form & Instructions
No automated form is available as PDF file is fillable

Contact Clarice Baldwin at DSSDB (916) 653-1308
AD 42R Agency Adoption Program – Individual Case Report Form & Instructions
No automated form is available as PDF file is fillable

Contact Clarice Baldwin at DSSDB (916) 653-1308
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
Contact Evangeline (Gigi) Sabile at DSSDB (858) 755-7291
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
Contact Candace Dunham for automated form at DSSDB (916) 653-1360
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 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. ACL
  • 3/06 form version, in use from March 2006 through June 2009 report months. ACL

7/09 Form & Instructions

3/06 Form & Instructions
7/09 Form: Contact Candace Dunham for automated report form at DSSDB (916) 653-1360

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. ACL
1/02 Form & Instructions Contact Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
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 Contact Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
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
Contact Sunit Mayall for automated report form at DSSDB (916) 657-1642
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 Contact Sunit Mayall for automated report form at DSSDB (916) 657-1642
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

Contact DSSDB at (916) 651-8269  for more information
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
Contact Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
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 Contact Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
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 Contact Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
COMMUNITY CARE LICENSING
LIC 181 Licensing of Facilities for Children Monthly Statistical Report
  • 12/01 form version, in use beginning December 2001 report month. ACL
12/01 Form & Instructions Contact Katie Girimonte for automated report form at DSSDB (916) 653-1363
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 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. ACL
1/00 Form & Instructions Contact Katie Girimonte for automated report form at DSSDB (916) 657-1363
GR 237 General Relief and Interim Assistance to Applicants for SSI/SSP Monthly Caseload and Expenditure Statistical Report ACIN Form & Instructions Contact Katie Girimonte for automated report form at DSSDB (916) 653-1363
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

Contact Sunit Mayall for automated report form at DSSDB (916) 657-1642
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 Contact Katie Girimonte for automated report form at DSSDB (916) 653-1363
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

Contact Eli Tuisku for automated report form at DSSDB (916) 653-1339
DPA 266 Fraud Investigation Activity Report
  • 7/04 form version, in use beginning July 2004 report month. ACL

7/04 Form & Instructions
Contact Eli Tuisku for automated report form at DSSDB (916) 653-1339
DPA 482 IEVS Management Report
  • 10/01 form version, in use beginning October - December 2001 report quarter. ACL
10/01 Form & Instructions Contact Eli Tuisku for automated report form at DSSDB (916) 653-1339
IMMIGRATION SERVICES 
IS-DACA Immigration Services Deferred Action for Childhood Arrivals (DACA) Application Assistance Quarterly Report
  • This form version is in use beginning January – March 2016 report quarter.


1/16 Form & Instructions
Contact Eli Tuisku for automated report form at DSSDB (916) 653-1339
IS-DAPA Immigration Services Deferred Action for Parents of Americans and Lawful Permanent Residents (DAPA) Application Assistance Quarterly Report
  • This form version is in use beginning January – March 2016 report quarter.


1/16 Form & Instructions
Contact Eli Tuisku for automated report form at DSSDB (916) 653-1339
IS-EO  Immigration Services Education and Outreach Quarterly Report
  • This form version is in use beginning January – March 2016 report quarter.

1/16 Form & Instructions
Contact Eli Tuisku for automated report form at DSSDB (916) 653-1339
IS-LTTA Immigration Services Legal Training and Technical Assistance Quarterly Report
  • This form version is in use beginning January – March 2016 report quarter.
1/16 Form & InstructionsContact Eli Tuisku for automated report form at DSSDB (916) 653-1339
IS-NAT Immigration Services Naturalization Application Assistance Quarterly Report

  • This form version is in use beginning January – March 2016 report quarter.
1/16 Form & Instructions Contact Eli Tuisku for automated report form at DSSDB (916) 653-1339
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
  • 7/16 form version, in use for July 2016 report month. ACIN
  • 7/15 form version, in use for July 2015 report month.  ACIN  
  • 7/14 form version, in use for July 2014 report month. ACIN

 

7/16 Form & Instructions

7/15 Form & Instructions


7/14 Form & Instructions 



Contact Christopher Tai for automated form at DSSDB (916) 653-1350