Exhibit_D_-_Monthly_CAPS_Household_Report.xlsx
XLSX spreadsheet 157 KB Posted
- Attached to
- Master Agreement AZ|CTR075477
- Contract number
- CTR075477
- Issued by
- Arizona
About this file
The document appears to be a standardized template for a Household Benefits Report, likely related to a government assistance program such as fuel assistance or social services. The template is structured for tracking household information across Federal Fiscal Years (FFY) 24 and 25, with detailed columns for capturing comprehensive household demographic and assistance data.
The template includes extensive fields for capturing individual and household-level information, including applicant personal details, address, household composition, vulnerable population indicators (elderly, disabled, children), income levels, and benefit specifics such as fuel assistance. The document provides a systematic approach for tracking assistance programs, with columns for service codes, benefit amounts, application dates, and optional agency comments. The template appears designed to standardize data collection and reporting for a social services or energy assistance program across multiple fiscal years.
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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 .