Form OCSE-34A Quarterly Financial Report

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Office of Child Support Enforcement

OMB APPROVED.

DRAFT

Control No. 0970-0181
Expires: 09/30/xxxx

CHILD SUPPORT ENFORCEMENT PROGRAM COLLECTION REPORT
PART 1: QUARTERLY REPORT OF COLLECTIONS
State:

Quarter Ended:

SECTION A.

Mark Box:
Initial Report

Revised Report

AVAILABLE COLLECTIONS

(G) Total

1. Balance Remaining Undistributed at End of Last Quarter (Carried from Line 9b of Previous Quarter)…………….….. $
$

2. Collections Received During the Quarter
2a. From Offset of
Federal Tax Refund..... $
2b.From Offset of
State Tax Refund......... $
2c. From Offset of
Unemployment Comp.. $
2d.Through Administrative Enforcement....... $

2e. From IV-D & Non-IV-D
Income Withholding......$
2f. From
Other States................. $
2g From
Other Countries….. $
2h From
Other Sources.......... $

3. Net Amount of Increasing and (Decreasing) Adjustments............................................................................................. $
$

4. Collections Sent During the Quarter Outside the Reporting State's IV-D Program
(A) Current
IV-A Assistance

(B) Current
IV-E Assistance

(C) Former
IV-A Assistance

(D) Former
IV-E Assistance

(E) Medicaid
Never Assistance

(F) Other
Never Assistance

(G) Total

4a Sent to Non
$

IV-D Families

4b. Sent to Other
States................ $

$

$

$

$

$

$

4c Sent to Other
$

Countries

5. (Reserved)
6. Remaining Collections Available for Distribution………………………………………………………………………………$

SECTION B.

DISTRIBUTED / UNDISTRIBUTED COLLECTIONS

(G) Total

7a. Passed
$

$

$

$

$

Reimburse...… $

$

$

$

$

$

$

$

$

$

$

$

Family or FC $

$

$

$

$

$

$

$

$

$

$

$

$

Through

7b. Dist As Assist
7c. Dist As Med
Support

7d. Dist To
7e Fees Retained
8.

9.

by State
Total
Distributed...... $

$

$

$

Gross Undistributed Collections.....………………….…………....................................................................................... $

$
9a. Undistributed Collections Determined Undistributable and Abandoned…………………………...…………………………
9b. Net Undistributed Collections (Report on Line 1, Part 2) (Carry forward to Line 1, Part 1, Next Quarter)………………$

SECTION C.

FEDERAL SHARE / FEES

(G) Total

10a. Fed Share of
$

IV-E Collect.

$

$

10b. Fed Share of
IV-A Collect.

$

$

$

11. Fees Retained By Other States…………………………………………………..………………………………………………$

This certifies that the information on this form is accurate and true to the best of my knowledge and belief.
Signature, IV-D Agency Director

Signature, Approving State Official
Date:

Typed Name, Title, Agency

Form OCSE-34A - Part 1 (10/01/2007)

Date:
Typed Name, Title, Agency

Replaces 10/01/2003 version, now obsolete.

mhb

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Office of Child Support Enforcement

DRAFT

OMB APPROVED.
Control No. 0970-0181
Expires: 09/30/xxxx

CHILD SUPPORT ENFORCEMENT PROGRAM COLLECTION REPORT
PART 2: ITEMIZED UNDISTRIBUTED COLLECTIONS
State:

Quarter Ended:

Mark Box:
Initial Report

Revised Report

1 Net Undistributed Collections - (from Line 9b, Part 1, of this report)
(Also equal to the sum of Lines 2 and 8 and the sum of Lines 14 through 20, below.)

$

SECTION A: NET UNDISTRIBUTED COLLECTIONS BY CATEGORY
2 Portion of Net Undistributed Collections Pending Distribution………………………………$
The amount in Item 1 must equal the sum of the amounts in Items 3 through 7. Attach any explanatory comments.

3 Collections Received Within The Past Two Business Days….....................................................…… $
4 Collections From Tax Offsets Being Held for Up To Six Months.............................……………………$
5 Collections Received and Being Held for Future Support................................................................... $
6 Collections Being Held Pending the Resolution of Legal Disputes..................................................... $
7 Collections Being Held Pending Transfer to Other State or Federal Agency...................................... $

8 Portion of Net Undistributed Collections Unresolved………………………………………… $
The amount in Item 7 must equal the sum of the amounts in Items 9 through 13. Attach any explanatory comments.

9 Unidentified Collections..........................................................................................................

$

10 Collections Being Held Pending the Location of the Custodial or Non-Custodial Parent.................... $
11 Collections Disbursed but Uncashed and Stale-Dated....................................................................... $
12 Collections With Inaccurate or Missing Information............................................................................ $
13 Other Collections Remaining Undistributed........................................................................................ $

SECTION B: NET UNDISTRIBUTED COLLECTIONS BY AGE
14 Collections Remaining Undistributed Up to 2 Business Days of Receipt…………………..……………$
15 Collections Remaining Undistributed More Than 2 Days, But Not More Than 30 Days……………… $
16 Collections Remaining Undistributed More Than 30 Days, But Not More Than 6 Months…………… $
17 Collections Remaining Undistributed More Than 6 Months, But Not More Than 1 Year…………...…$
18 Collections Remaining Undistributed More Than 1 Year, But Not More Than 3 Years……………..…$
19 Collections Remaining Undistributed More Than 3 Years, But Not More Than 5 Years…………..……
$
20 Collections Remaining Undistributed More Than 5 Years…............................................................... $
Form OCSE-34A - Part 2

(10/01/2007)

Replaces OCSE Schedule UDC, now obsolete.

mhb