Exhibit_D_-_Monthly_CAPS_Household_Report.xlsx
XLSX spreadsheet 157 KB Posted
- Attached to
- Master Agreement AZ|CTR075436
- Contract number
- CTR075436
- Issued by
- Arizona
About this file
The document appears to be a monthly household benefits reporting template for a government assistance program, likely related to fuel or heating assistance. The template is structured for two fiscal years (FFY 24 and FFY 25) and contains comprehensive data collection fields for tracking household-level information, including applicant demographics, household composition, income, and vulnerability status.
The template captures detailed household data including applicant personal information, address details, household size, income, and specific vulnerability markers such as elderly members, disabled individuals, and children in different age brackets. The primary focus seems to be on tracking benefits related to fuel assistance, with fields for application date, service code, benefit amount, main heating fuel type, and optional agency and DCAD comments. The spreadsheet is designed to systematically record and track household-level assistance program participation and characteristics across different fund sources and provider networks.
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Text version
HOUSEHOLD Template FFY 25 blank
| PROGRAM | Prov ID | HH Information | Vulnerable in Household (Y/N) | Benefit/Assistance Information | Agency | INTERNAL |
| FUND SOURCE CODE | Provider Name (TON) | Applicant |
First Name Applicant Middle Initial Applicant Last
| Name | Applicant | |
| SSN OR CENSUS ID | Applicant | |
| Street Address | Applicant | |
| Unit/Apt # | Applicant | |
| City | Applicant | |
| State | Applicant | |
| Zip Code | # in HH | Household |
Income (30 Days) Elderly (60+) Disabled Child 2 and Under (under 3) (2yrs 364 days yrs or younger) Y/N Child 3 -5 (5 yrds 364 days of age) Y/N Benefit Fuel Fuel (Paid For) Main Heating fuel (Fuel used to Heat the Home) Application date Service Code (regular or Supplemental Benefit Amount AGENCY COMMENT (OPTIONAL) DCAD COMMENT
HOUSEHOLD Template FFY 24 Notes
| PROGRAM | Prov ID | HH Information | Vulnerable in Household (Y/N) | Benefit/Assistance Information | Agency | INTERNAL |
| FUND SOURCE CODE | Provider Name | Applicant |
First Name Applicant Middle Initial Applicant Last
| Name | Applicant | |
| SSN or CID | Applicant | |
| Street Address | Applicant | |
| Unit/Apt # | Applicant | |
| City | Applicant | |
| State | Applicant | |
| Zip Code | # in HH | Household |
Income (30 Days) Elderly (60+) in Home Disabled (Y/N) Child 2 and Under (under 3) (2yrs 364 days yrs or younger) Child 3 -5 (5 yrds 364 days of age) Benefit Fuel Fuel (Paid For) Main Heating fuel (Fuel used to Heat the Home) Application date Service Code Benefit Amount AGENCY COMMENT DCAD COMMENT
File details come from the government source that posted it. Updated .