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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.

Files that are listed as "Pending" in the last column, "Link to Blank Form in Excel" will be added soon.

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 Link to Blank Form in Excel
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 Food Stamp Program Expedited Service Quarterly Statistical Report
  • 10/04 form version, in use beginning October - December 2004 report quarter. Link to ACL

Link to 10/04
Form & Instructions
Contact Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
DFA 358F CalFresh Participants by Ethnic Group - Federal-Only and Combined Households
  • 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
  • 7/10 form version, in use for July 2010 report month.
  • 7/09 form version, in use for July 2009 report month.
  • 7/08 form version, in use for July 2008 report month. Link to ACIN   
Link to 7/12
Form & Instructions

Link to 7/11
Form & Instructions

Link to 7/10
Form & Instructions

Link to 7/09
Form & Instructions

Link to 7/08
Form & Instructions
Link to 7/12
Form

Link to 7/11
Form

Link to 7/10
Form

Link to 7/09
Form

Link to 7/08
Form
DFA 358S CalFresh Participants by Ethnic Group - State-Only Households
  • 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
  • 7/10 form version, in use for July 2010 report month.
  • 7/09 form version, in use for July 2009 report month.
  • 7/08 form version, in use for July 2008 report month. Link to ACIN   
Link to 7/12
Form & Instructions

Link to 7/11
Form & Instructions

Link to 7/10
Form & Instructions

Link to 7/09
Form & Instructions

Link to 7/08
Form & Instructions
Link to 7/12
Form

Link to 7/11
Form

Link to 7/10
Form

Link to 7/09
Form

Link to 7/08
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 Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
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 Tracy Ahlenstorf for automated report form at DSSDB (916) 653-1322
CalWORKs
CA 237 CW CalWORKs Cash Grant Caseload Movement Report
  • 7/12 form version, in use beginning July 2012 report month.  Link to ACL
  • 12/02 form version, in use from December 2002 through June 2012 report months.  Link to ACL
Link to 7/12
Form & Instructions

Link to 12/02
Form & Instructions 		Contact Marina Guzman for automated report form at DSSDB (916) 653-1304
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 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
  • 5/04 form version, in use beginning May 2004 report month.  Link to ACL

Link to
Form & Instructions
Contact Marina Guzman for automated report form at DSSDB (916) 653-1304
CA 255 CW CalWORKs Report on Reasons for Denials and Other Non-Approvals of Applications for Cash Grant
  • 12/02 form version, in use beginning December 2002 report month.  Link to ACL

Link to
Form & Instructions
Contact Marina Guzman for automated report form at DSSDB (916) 653-1304
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 Ruxandra Turcu 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 Ruxandra Turcu for automated report form at DSSDB (916) 653-1339
STAT 45 Cal-Learn Program Teen Parent Monthly Status Report
During the Cal-Learn suspension period of July 1, 2011 through June 30, 2012, the STAT 45 report was renamed Welfare-to-Work (WTW) Teen Parent Monthly Status Report.

  • 4/13 form version, in use beginning April 2013 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 4/13 Form & Instructions


Link to 7/11 Form & Instructions


Link to 1/02 
Form & Instructions 		Contact Sandra Da Silva 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.   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
WTW - AB 98 CalWORKs Subsidized Employment Claimed Under AB 98
  • 1/09 form version, in use beginning January 2009 report month. Link to ACL

NOTE: All County Letter 09-71 suspended submission of the WTW-AB 98 for report months August 2009 through September 2010. The suspension period ended as of the September 2010 report month.  Participating counties are to resume reporting with their October 2010 reports.  Link to ACL

Link to 1/09
Form & Instructions (PDF)   		Link to 1/09 Form (Excel)  
WTW - ARRA CalWORKs Subsidized Employment Claimed Toward the American Recovery and Reinvestment Act (ARRA) of 2009 TANF Emergency Contingency Fund (ECF) 
  • 10/09 form version, in use from October 2009 through September 2010 report months. 

NOTE:  All County Letter 10-04 dated February 3, 2010 indicates that the last reporting month is September 2010.
Link to ACL

Link to 
Form & Instructions
Not available    		For more information, contact Roland Fong at DSSDB (916) 653-1349
CHILDREN'S PROGRAMS
AD 42I Independent Adoption Program – Individual Case Report Link to
Form & Instructions
No Excel file is available as PDF file is fillable
AD 42R Agency Adoption Program – Individual Case Report Link to
Form & Instructions
No Excel file is available as PDF file is fillable
AD56A Agency Adoption Program Quarterly Statistical Report
  • 10/01 form version, in use beginning October - December 2001 report quarter.
Link to
Form & Instructions 		Contact Nancy Marker at DSSDB (916) 654-2121 
AD56D 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 Nancy Marker at DSSDB (916) 654-2121 
AD202B 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 Nancy Marker at DSSDB (916) 654-2121 
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) 653-1321

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 Gigi Sabile for automated report form at DSSDB (858) 755-7291
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 Gigi Sabile for automated report form at DSSDB (858) 755-7291
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) 653-1321
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) 653-1321
FC 23 Probation Foster Care Placement Monthly Caseload Statistical Report
  • 1/05 form version, in use beginning January 2005 report month.  Link to ACL

Link to Form & Instructions
Contact Adriana Neves for automated report form at DSSDB (916) 653-1321
FC-AAP 84  Supplement to the Rate Requests for Dual Agency AFDC-FC and AAP Children Quarterly Statistical Report 
  • 1/09 form version, in use beginning January-March 2009 report quarter.  Link to ACL

Link to Form & Instructions  
Contact Clarice Baldwin for automated report form at DSSDB (916) 653-1308
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)
  • Oct11 (SOC 405A.1) form version, in use October 1, 2011 through September 30, 2012 report period.  Link to ACIN pending.
  • 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) 653-1321




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 Marina Guzman for automated report form at DSSDB (916) 653-1304
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 Sandra Da Silva for automated report form at DSSDB (916) 653-1354
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 Candace Dunham for automated report form at DSSDB (916) 653-1360
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 Sandra Da Silva for automated report form at DSSDB (916) 653-1354
SOC 242 Adult Protective Services and County Services Block Grant Monthly Statistical Report
  • 9/13 form version, in use beginning September 2013 report month.   Link to ACL
  • 4/07 form version, in use from April 2007 through August 2013 report months.   Link to ACL   


Link to 9/13 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 Ruxandra Turcu 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, Nonassistance Food Stamps, CalWORKs Welfare to Work, Refugee Cash Assistance, and the Cash Assistance Program for Immigrants Ethnic Origin and Primary Language
  • 7/12 form version, in use for July 2012 report month.
  • 7/11 form version, in use for July 2011 report month.
  • 7/10 form version, in use for July 2010 report month.  
  • 7/09 form version, in use for July 2009 report month.
  • 7/08 form version, in use for July 2008 report month.   Link to ACIN
Link to 7/12
Form & Instructions

Link to 7/11
Form & Instructions

Link to 7/10
Form & Instructions

Link to 7/09
Form & Instructions

Link to 7/08
Forms & Instructions 		Link to 7/12
Form

Link to 7/11
Form

Link to 7/10
Form

Link to 7/09
Form

Link to 7/08
Form