Exhibit_D_-_Monthly_CAPS_Household_Report.xlsx
XLSX spreadsheet 157 KB Posted
- Attached to
- Master Agreement AZ|CTR075490
- Contract number
- CTR075490
- Issued by
- Arizona
About this file
The document appears to be a household benefits reporting template for a government assistance program, specifically a Monthly CAPS (Community Action Program Services) Household Report. The template is designed for tracking household information across two fiscal years (FFY 24 and FFY 25) and contains comprehensive data fields for applicant and household demographic details, including income, vulnerable population status, and household composition.
The template captures detailed information about household benefits, focusing on fuel assistance and heating support. Key data points include applicant personal information, household size, income, vulnerable population indicators (such as elderly, disabled, or households with young children), and benefit-related details like fuel type, application date, service code, and benefit amount. The document appears to be a standardized reporting tool for tracking and managing household assistance program participation, with fields for agency and internal fund source tracking.
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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 .