Form 396 OCSE-396

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

OMB APPROVED
Control No. 0970-0181
Expires: XX/XX/2020

FORM OCSE-396: CHILD SUPPORT ENFORCEMENT PROGRAM QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES
State:

Current (Claiming)
Quarter Ended:

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

66% FFP rate for all cost
categories, except where noted

SECTION A.

Next (Estimating)
Quarter Ending:

Mark
Box:

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

Initial Report
Rev'd Report

Next Quarter Estimate
(E) Total
(F) Federal Share

EXPENDITURES

1a. Admin. Costs w/ Incentive
Payments (No FFP)

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

1b. Administrative Costs:
Reguar

1c Administrative Costs:
Non-IV-D:

1d Admin Costs w/ Incentives
Under Waiver (No FFP):

$

$

$

2a. Program Income:
Fees, Costs Recovered:

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

2b. Program Income:
Interest, Other

3. Net Administrative
Costs:

4. ADP Development Costs
with APD Required:

5. ADP Operational Costs
with APD Required

6. (Reserved)
7. Total Costs
Claimed:

SECTION B.

FEES FOR SERVICES / FEDERAL & STATE SHARES of COSTS

8. (Reserved)
9. Federal Share of Title IV-A
Child Support Collections:

10. Fees Federal FPLS:
11. Fees CSENet:
12. Fees Pre-Offset Service:
13. Adjustments:
14. Net Federal Share of
Expenditures:
15. State Share of
Expenditures:

SECTION C.

From Form OCSE-34
Line 10b, Col G ==>
Enter Total Fee in
Column B ===>
Enter Total Fee in
Column B ===>
Enter Total Fee in
Column B ===>
Enter Total Amount in
Column B ===>

$

$

$
$
$
$
$

Enter State Share Only
in Column B ===>

$

Enter State Share Only
in Column D ===>

$

$

$

$

INCENTIVE PAYMENTS

16. Estimate of Earned
$

Incentive Payments:

This certifies that the information on this form is accurate and true to the best of my knowledge and belief. This also certifies that the State share of expenditures estimated
for the Next Quarter are, or will be, available as required by law
Signature, IV-D Agency Director
Signature, Approving Official
Date:
Typed Name, Title, Agency

Form OCSE-396 - Part 1 (10/01/2017)

Date:
Typed Name, Title, Agency

Replaces Previous Version.

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U.S Department of Health and Human Services

OMB APPROVED

Office of Child Support Enforcement

Control No. 0970-0181
Expires: 05/31/2017

FORM OCSE-396: CHILD SUPPORT ENFORCEMENT PROGRAM QUARTERLY FINANCIAL REPORT
PART 2: PRIOR QUARTER EXPENDITURE ADJUSTMENTS

State:

Current (Claiming)
Quarter Ended:

(B) Federal Share of
Adjustments

(A) Total Adjustment

(C) Funding Category

(D) Applicable to Fiscal
Quarter Ended

Mark
Box:

Initial Report
Revised Report

(E) Adjustment Identification and Explanation
(if applicable)

SECTION A: INCREASING ADJUSTMENTS
$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

<=== TOTAL INCREASING ADJUSTMENTS

SECTION B: DECREASING ADJUSTMENTS
$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

<=== TOTAL DECREASING ADJUSTMENTS

$

$

<=== NET ADJUSTMENTS (Section A minus Section B)

* Funding Categories:

(with equivalent line numbers from Part 1):

CEN - Administrative Costs Using Incentive Payments (66% FFP Rate: FY 2009-2010, Otherwise 0% FFP Rate): Line 1a.
ADM - Administrative Costs (66% FFP Rate): Lines 1b and 1c
CENW - Administrative Costs Using Incentive Payments Under Waiver (0% FFP Rate): Line 1d.
INC - Program Income from fees, interest, etc. (66% FFP Rate): Lines 2a and 2b
DEV - CSES Developmental Costs with an Approved Advanced Planning Document (APD) (66% FFP Rate): Line 4
OPN - CSES Operational Costs with an Approved Advanced Planning Document (APD) (66% FFP Rate): Line 5
ADP - CSES Costs where an Approved Advanced Planning Document (APD) is not required (66% FFP Rate): Line 6

Form OCSE-396 - Part 2 (10/01/2017)

Unchanged from 10/01/2014 version.

mhb