Form CB-496 IV-E, Program Quarterly Financial Report

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Administration on Children, Youth and Families
Children's Bureau

OMB APPROVED
Control No. 0970-0205
Expires 09/30/20xx

DRAFT MAY 2010

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES
State/Tribe:

Current (Claiming)
Quarter Ended:

Next (Estimating)
Quarter Ending:

Mark
Box:

Initial Report
Rev'd Report

SECTION A: FOSTER CARE PROGRAM
50% FFP rate for all cost categories,
except where noted
Maintenance Assistance
1
Payments (FMAP rate)
Tribe/State Agreement Maint Assist
2
STATES Payments (Applicable FMAP Rate)
Federal Share of Child Support
3
Collections - From Form OCSE-34A
Net Maintenance Assistance
4
Payments
In-Placement Administrative Costs 5
Case Planning and Management
In-Placement Administrative Costs 6
Eligibility Determinations
In-Placement Administrative Costs 7
Provider Management
In-Placement Administrative Costs 8
Agency Management
Total In-Placement
9
Administrative Costs
10 Candidate Administrative Costs Pre Placement Activities

Current Quarter Claims
(A) Total
(B) Fed Share

Prior Quarter Adjustments
(C) Total
(D) Fed Share

Next Quarter Estimates
(E) Total
(F) Fed Share

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

SACWIS Operational Costs
SACWIS Developmental Costs:
Project 1 - APD Required
SACWIS Developmental Costs:
Project 2 - APD Required
Other SACWIS Costs
No APD Required
Training Costs - Staff and Provider
(75% FFP Rate)
Training Costs - Professional
Partner (Transitional FFP Rate)
Demonstration Project Costs From Part 3, Line 17

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Total Costs

$

$

$

$

$

$

11
12
13
14
15
16
17
18
19
20
TRIBES

Non-Federal (State or Tribe)
Share of Total Costs
Tribal Share of Costs from
Third Party In-Kind Sources

$

$

$

$

$

$

Prior Quarter Adjustments
(C) Total
(D) Fed Share

Next Quarter Estimates
(E) Total
(F) Fed Share

SECTION B: ADOPTION ASSISTANCE PROGRAM
Current Quarter Claims
(A) Total
(B) Fed Share
21
22
STATES

23
24
25
26
27

Adoption Assistance
Payments (FMAP rate)
Tribe/State Agreement Adopt Assist
Payments (Applicable FMAP Rate)
Administrative Costs Agency
Administrative Costs Non-Recurring
Training Costs - Staff and Provider
(75% FFP Rate)
Training Costs - Professional
Partner (Transitional FFP Rate)
Demonstration Project Costs
From Part 3, Line 17
Total Costs

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

28
29
30
TRIBES

Non-Federal (State or Tribe)
Share of Total Costs
Tribal Share of Costs from
Third Party In-Kind Contributions

$

$

$

$

$

$

Form CB- 496 [Part 1 - Page 1 of 2] (10/01/2010) Replaces Form ACF-IV-E-1, now obsolete.

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Administration on Children, Youth and Families
Children's Bureau

OMB APPROVED
Control No. 0970-0205
Expires 09/30/20xx

DRAFT MAY 2010

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES
State/Tribe:

Current (Claiming)
Quarter Ended:

Next (Estimating)
Quarter Ending:

Mark
Box:

Initial Report
Rev'd Report

SECTION C: GUARDIANSHIP ASSISTANCE PROGRAM
50% FFP rate for all cost categories,
except where noted
31 Guardianship Assistance
Payments (FMAP rate)
32 Tribe/State Agreement Guard Assist
STATES Payments (Applicable FMAP Rate)
33 Administrative Costs Agency
34 Administrative Costs Non-Recurring
35 Training Costs - Staff and Provider
(75% FFP Rate)
36 Train. Costs - Relative Guardian and
Pro Partner (Transitional FFP Rate)
37 Post Demonstration Guardianship
STATES Assistance and Services Costs
38 Total Costs

39
40
TRIBES

Current Quarter Claims
(A) Total
(B) Fed Share

Prior Quarter Adjustments
(C) Total
(D) Fed Share

Next Quarter Estimates
(E) Total
(F) Fed Share

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Non-Federal Share of
of Total Costs
Tribal Share of Costs from
Third Party In-Kind Sources

$

$

$

$

$

$

SECTION D: AVERAGE MONTHLY NUMBER OF CHILDREN ASSISTED
Actual Count
Current Quarter

Estimated Count
Next Quarter

FOSTER CARE PROGRAM
41
42
43
44

Number of Children:
In-Placement - Title IV-E Maintenance Assistance Payments
Number of Children:
In-Placement - Title IV-E Funded Administrative Costs
Number of Children:
In-Placement - Any Payments or Administrative Costs
Number of Children:
Pre-Placement - Title IV-E Maintenance Assistance Payments

ADOPTION ASSISTANCE PROGRAM
45
46
47

Number of Children:
Title IV-E Assistance Payments
Number of Children:
Any Assistance Payments
Number of Children:
Title IV-E Non-Recurring Administrative Cost Payments

GUARDIANSHIP ASSISTANCE PROGRAM
48
49
50
51

Number of Children:
Title IV-E Assistance Payments
Number of Children:
Any Assistance Payments
Number of Children:
Title IV-E Non-Recurring Administrative Cost Payments
Number of Children:
Title IV-E Post Demonstration Assistance or Services
This certifies that the information on all parts of this form is accurate and true to the best of my knowledge and belief.
This also certifies that the "Next Quarter" estimates of the Non-Federal shares of expenditures for each title IV-E program
on Part 1 of these forms are, or will be available as required by law.

Signature, Approving Official

Typed Name, Title, Agency

Form CB-496 [Part 1 - Page 2 of 2] (10/01/2010) Replaces Form ACF-IV-E-1, now obsolete.

Date:

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Administration on Children, Youth and Families
Children's Bureau

OMB APPROVED Control
No. 0970-0205 Expires
09/30/20xx

DRAFT MAY 2010

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 2: PRIOR QUARTER EXPENDITURE ADJUSTMENTS
(Attach this report to Part 1. Use as many attachments as necessary.)

Applicable Program:

Foster Care

Adoption Assistance

Guardianship Assistance

Current (Claiming)
Quarter Ended:

State/Tribe:

(B) Federal Share
of Adjustment

(A) Total
Adjustment

(C) Funding
Category *

Mark
Box:

(D) Applicable to
Fiscal Quarter Ended

(E)

Initial Report
Revised Report

Federal Audit Number (if applicable),
Other Comments

SECTION A: INCREASING ADJUSTMENTS
$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

<=== TOTAL INCREASING ADJUSTMENTS

SECTION B: DECREASING ADJUSTMENTS
$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

* Funding Categories:

<=== TOTAL DECREASING ADJUSTMENTS
<=== NET ADJUSTMENTS (Section A Totals minus Section B Totals)

(with equivalent line numbers from Part 1):

Foster Care Maint Assist Payments (Line 1)
Foster Care Maint Assist Payments w/Agreement (Line 2 )
Foster Care Admin - Case Planning & Mgmt (Line 5 )
Foster Care Admin - Eligibility Determinations (Line 6)
Foster Care Admin - Provider Mgmt (Line 7)
Foster Care Admin - Agency Prog Mgmt (Line 8)

APY
APA
AAD
AAN
ATS
ATP

FCP

Candidate Admin - Pre-Placement (Line 10)

ADE

Adoption Demo Project Costs (Line 27)

FSO

SACWIS Admin - Operational Costs (Line 11)

GPY

Guardianship Assist Payments (Line 31)

FPY
FPA
FAC
FAE
FAM
FAA

Adoption Assist Payments (Line 21)
Adoption Assist Payments w/ Agreement (Line 22)
Adoption Admin - Agency (Line 23 )
Adoption Admin - Non-Recurring (Line 24)
Adoption Training Costs - Staff & Provider (Line 25)
Adoption Training Costs - Professional Partners (Line 26)

FS1

SACWIS Development Costs - Project 1 (Line 12)

GPA

Guardianship Assist Payments w/ Agreement (Line 32)

FS2

SACWIS Development Costs - Project 2 (Line 13)

GAD

Guardianship Admin - Agency (Line 33)

FTS

Foster Care Training Costs - Staff & Provider (Line 15)

GAN

Guardianship Admin - Non-Recurring (Line 34)

FTP

Foster Care Training Costs - Professional Partners (Line 16)

GTS

Guardianship Training Costs - Staff & Provider (Line 35)

FDE

Foster Care Demo Project Costs (Line 17)

GTP

Guardianship Training Costs - Professional Partners (Line 36)

GPD

Guardianship Post-Demo Project Costs (Line 37)

Form CB-496 [Part 2] (10/01/2010) Replaces Form ACF-IV-E-1, now obsolete.

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Administration on Children, Youth and Families
Children's Bureau

OMB APPROVED
Control No. 0970-0205
Expires 09/30/20xx

DRAFT MAY 2010

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 3: DEMONSTRATION PROJECTS
(Attach this report to Part 1.)

Foster Care

Applicable Program:

Adoption Assistance

Current (Claiming)
Quarter Ended:
Current Quarter Claims
Prior Quarter Adjustments
(A) Total
(B) Fed Share
(C) Total
(D) Fed Share

State:

Mark
Initial Report
Box:
Revised Report
Next Quarter Estimates
(F) Total
(G) Fed Share

Total Expenditures

(E) Fed Share

SECTION A: PROJECT COSTS
1
2
3
4
5

Experimental Group
Operations
Control Group
Operations
Developmental &
Evaluations
Total Costs
Claimed

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

State Share of
Costs Claimed

$

SECTION B: COST NEUTRALITY
6
7
8
9
10
11

Cumulative Experimental
Group CNL
Cumulative Experimental
Group Oper Costs
Cumulative Control Group
Operational Costs
Experimental Group
Oper Costs > CNL
Total
Costs
Remaining
Available

Sum of Current and Prior Qtr Fed Shares in Col. D --> $

$

$

Sum of Current and Prior Qtr Fed Shares in Col. D --> $

$

$

Sum of Current and Prior Qtr Fed Shares in Col. D --> $

$

$

Sum of Current and Prior Qtr Fed Shares in Col. D --> $
$

$

$

$

$

$

Sum of Current and Prior Qtr Fed Shares in Col. D --> $

$

$
$

$

$

$

SECTION C: SAVINGS
12
13
14
15
16

Cumulative Savings
Realized
Prior Cumulative Savings
Balance
Total Savings
Available
Available Savings
Expended In Qtr
Cumulative Savings
Expended

Sum of Current and Prior Qtr Fed Shares in Col. D --> $
$

$

$

$

Sum of Current and Prior Qtr Fed Shares in Col. D --> $

$
$
$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

SECTION D: CLAIMS/ESTIMATES
17

Total

$

Form CB-496 [Part 3] (10/01/2010) Replaces Form ACF-IV-E-1, now obsolete.