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OMB Control No: 0970-0205 |
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| DEPARTMENT OF HEALTH AND HUMAN SERVICES |
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Expiration date: 3/31/2001 |
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| Aministration for Children and Families |
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Form ACF-IV-E-1 |
| TITLE IV-E FOSTER CARE AND ADOPTION ASSISTANCE FINANCIAL REPORT |
| PART 1 : QUARTERLY REPORT OF EXPENDITURES AND ESTIMATES |
| THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) |
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| Public reporting burden for this collection of information is estimated to average 8 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing |
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| the collection of information. |
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| An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. |
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| STATE: |
CURRENT QUARTER ENDED: |
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NEXT QUARTER ENDING: |
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New (N) or Revised (R): |
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| CATEGORY |
Current Quarter Expenditures |
Prior Quarter Adjustments |
Next Quarter Estimate |
| FOSTER CARE |
(a) Total Computable |
(b) Federal Share * |
(c) Total Computable |
(d) Federal Share |
(e) Total Computable |
(f) Federal Share* |
| FMAP Rate: |
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| 1. Maintenance Assistance Payments |
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| 2. Fed. share Child Support Collections |
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| 3. Net Assistance Payments (1 minus 2) |
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| 4. Avg. Monthly No. of Children |
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| 5. State and Local Administration: . a. Case Planning & Management |
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| b. Pre-placement Activities |
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| c. Eligibility Determinations |
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| d. SACWIS - Operation costs |
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| e. Other Administration |
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| f. Total State and Local Administration . (a+b+c+d+e) |
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| 6. SACWIS - Development costs |
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| 7. State and Local Training |
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| 8. Demonstration Projects |
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| 9. Total ** |
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| 10. State share of next quarter Foster Care estimate [ Line 9(e) minus 9(f) ] ... |
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| *The Federal share percentage of total computable for payments is the FMAP rate, administration is 50%, SACWIS is 50% and training is 75%. |
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| **For Line 9, Col. (a), (c), (d) & (e) = Lines 1+5(f) +6+7+8. Col. (b) & (f) = Lines 3+5(f)+6+7+8. |
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| DEPARTMENT OF HEALTH AND HUMAN SERVICES |
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| Aministration for Children and Families |
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Form ACF-IV-E-1 |
| TITLE IV-E FOSTER CARE AND ADOPTION ASSISTANCE FINANCIAL REPORT |
| PART 1: QUARTERLY REPORT OF EXPENDITURES AND ESTIMATES |
| STATE: |
CURRENT QUARTER ENDED: |
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NEXT QUARTER ENDING: |
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New (N) or Revised (R): |
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_______________ |
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| CATEGORY |
Current Quarter Expenditures |
Prior Quarter Adjustments |
Next Quarter Estimate |
| ADOPTION ASSISTANCE |
(a) Total Computable |
(b) Federal Share * |
(c) Total Computable |
(d) Federal Share |
(e) Total Computable |
(e) Federal Share * |
| FMAP Rate: |
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| 1. Adoption Assistance Payments |
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| 2. Avg. Monthly No. of Children |
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| 3. State and Local Administration |
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| 4. State and Local Training |
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| 5. Demonstration Projects |
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| 6. Total (Lines 1+3+4+5) |
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| 7. State share of next quarter Adoption Assistance estimate [ Line 6(e) minus 6(f) ] ... |
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| *The Federal share percentage of total computable for payments is the FMAP rate, administration is 50% and training is 75%. |
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| This is to certify that all information reported on all parts of this form is accurate and true to the best of my knowledge and belief. This also certifies that the State's share of next quarter estimate |
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| reported in Part 1 for Foster Care and Adoption Assistance is or will be available to meet the non-Federal share of expenditures as required by law. |
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| Signature of Approving Official |
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Date |
Typed Name, Title, Agency Name |
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| Send completed form to: |
DHHS, ACF, ACYF |
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Send a copy to your Regional Office |
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Office of Management Services |
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330 C Street, S.W. |
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Washington, D. C. 20447 |
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| DEPARTMENT OF HEALTH AND HUMAN SERVICES |
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| Aministration for Children and Families |
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FC |
Form ACF-IV-E-1 |
| TITLE IV-E FOSTER CARE AND ADOPTION ASSISTANCE FINANCIAL REPORT |
| PART 2 : PRIOR QUARTER ADJUSTMENTS - FOSTER CARE |
| STATE: |
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CURRENT QUARTER ENDING: |
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Part 2 Page No. |
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| SECTION A: INCREASING ADJUSTMENTS |
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| (a) Part 1 |
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| Funding |
(b) For Quarter |
(c) Total Computable |
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(e) Audit No. (If Applicable) |
| Activity * |
Ended (Mo/Yr) |
Adjustment |
(d) Federal Share |
Other Comments |
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| SECTION B: DECREASING ADJUSTMENTS |
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| (a) Part 1 |
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| Funding |
(b) For Quarter |
(c) Total Computable |
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(e) Audit No. (If Applicable) |
| Activity * |
Ended (Mo/Yr) |
Adjustment |
(d) Federal Share |
Other Comments |
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| * FOSTER CARE FUNDING ACTIVITIES |
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| Line 1. FC Payments = FPY |
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Line 7. FC Training = FTR |
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| Lines 5a.- 5e. FC Admin. = FAD |
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Line 8. Demo. Projects = FDE - see |
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| Line 6. SACWIS 50% = SAC50 |
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instructions for Part 4. |
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| or SACWIS 75% = SAC75 |
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| DEPARTMENT OF HEALTH AND HUMAN SERVICES |
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| Aministration for Children and Families |
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AA |
Form ACF-IV-E-1 |
| TITLE IV-E FOSTER CARE AND ADOPTION ASSISTANCE FINANCIAL REPORT |
| PART 2 : PRIOR QUARTER ADJUSTMENTS - ADOPTION ASSISTANCE |
| STATE: |
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CURRENT QUARTER ENDING: |
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Part 2 Page No. |
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| SECTION A: INCREASING ADJUSTMENTS |
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| (a) Part 1 |
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| Funding |
(b) For Quarter |
(c) Total Computable |
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(e) Audit No. (If Applicable) |
| Activity * |
Ended (Mo/Yr) |
Adjustment |
(d) Federal Share |
Other Comments |
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| SECTION B: DECREASING ADJUSTMENTS |
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| (a) Part 1 |
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| Funding |
(b) For Quarter |
(c) Total Computable |
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(e) Audit No. (If Applicable) |
| Activity * |
Ended (Mo/Yr) |
Adjustment |
(d) Federal Share |
Other Comments |
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| * ADOPTION ASSISTANCE FUNDING ACTIVITIES |
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| Line 1. AA Payments = APY |
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Line 4. AA Training = ATR |
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| Line 3. AA Admin. = AAD |
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Line 5. Demo. Projects = ADE - see |
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instructions for Part 4. |
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| DEPARTMENT OF HEALTH AND HUMAN SERVICES |
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| Aministration for Children and Families |
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From ACF-IV-E-1 |
| TITLE IV-E FOSTER CARE AND ADOPTION ASSISTANCE |
| PART 4 : DEMONSTRATION PROJECTS |
| STATE: |
CURRENT QUARTER ENDED: |
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NEXT QUARTER ENDING: |
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Foster Care: |
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New(N) or Revised(R) |
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Adoption : |
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| CATEGORY |
Current Quarter Expenditures |
Prior Quarter Adjustments |
Total Expenditures |
Next Quarter Estimate |
| A. Quarterly Demonstration Costs |
(a) Total Computable |
(b) Federal Share |
(c) Total Computable |
(d) Federal Share |
(e) Federal Share |
(f) Total Computable |
(g) Federal Share |
| 1. Experimental Group Operational Exp. |
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| 2. Control/Comparison Group Operational Exp. |
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| 3. Total Demonstration Operational Exp. (1 plus 2) |
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| 4. Developmental and Evaluation Exp. |
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| 5. Total Expenditures (3 plus 4) |
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| 6. State share of next quarter estimate for Demonstration Projects ( 5 col (f) minus 5 col (g)) ... |
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| B. Cost Neutrality Calculation |
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| 7a. Cumulative Experimental Grp. Cost Neutrality Limit (CNL)* |
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| b. Cumulative Experimental Grp. Operational Exp. |
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| c. Cumulative Control/Comparison Grp. Operational Exp. |
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| d. Experimental Group Oper. Exp. in Excess of CNL |
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| e. Total Qrtly. Reimbursable. Exp. (5 (col e & g) minus 7d) |
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| f. Remaining Current Plus Prior Exp. (Holding Acct.)** |
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| C. Savings Calculation |
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| 8a. Cumulative Savings Realized. (7a minus 7b) |
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| b. Cumulative Savings Prev. Exp. (from 8e prior qtrly. report) |
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| c. Total Savings Available for Exp. (8a minus 8b) |
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| d. Quarterly Expenditure of Available Savings |
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| e. Cumulative Expenditure of Savings (8b plus 8d) |
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| D. Quarterly Claim/Estimate |
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| 9. Total (7e minus 2 plus 8d) |
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| *CNL equals calculated amount per approved formula. |
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| **Line 5 minus 7e. Holding account amounts may be used within the constraints of 45 CFR 95.7.as a portion of the exp. of available savings. Amounts will be deemd as incurred in the current quarter of the quarterly |
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| report on which reported. |
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