Form OCSE 34A OCSE 34A OCSE 34A

Page 1
U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Office of Child Support Enforcement

OMB APPROVED.
Control No. 0970-0181
Expires: 09/30/2010

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, Part 1 of Previous Quarter)……………. $
2. Collections Received During the Quarter…………………………………..……………………………………………………… $
2a. From Offset of
2e. From IV-D & Non-IV-D
Income Withholding....... $
Federal Tax Refund....... $
2b. From Offset of
2f. From
Other States.................. $
State Tax Refund...........$
2c. From Offset of
2g From
Other Countries……….. $
Unemployment Comp.... $
2d. Through Administra2h From
Other Sources.............. $
tive Enforcement.........$
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

4a Sent to Non IV-D
Families………………
4b. Sent to Other
States...................... $
4c. Sent to Other
Countries……………

(B) Current IV-E
Assistance

(C) Former IV-A
Assistance

(D) Former IV-E
Assistance

(E) Medicaid Never
Assist.

(F) Other Never
Assistance

(G) Total

$
$

$

$

$

$

$
$

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

SECTION B.

DISTRIBUTED / UNDISTRIBUTED COLLECTIONS

(G) Total

7a. Collections
Passed Through………$

$

$

7b. Dist As Assistance
Reimbursement………$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

7c. Dist As Medical
Support…………………$

7d. Distributed To
Family or FC………… $

7e. Fees Withheld
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

Page 2
U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Office of Child Support Enforcement

OMB APPROVED.
Control No. 0970-0181
Expires: 09/30/2010

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 2 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 8 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