Form CB-496 Title IV-E Programs Quarterly Financial Report

DRAFT - MAY 2013

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

OMB APPROVED
Control No. 0970-0205
Expires XX/XX/2016

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES (Including Caseload Data)
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

1
2
STATES

3
STATES

4
5
6
7
8
9
10

Maintenance Assistance
Payments (FMAP rate)
Tribal/State Agreement Maint Assist
Payments (Applicable FMAP Rate)
Federal Share of Child Support
Collections - From Form OCSE-34
Net Maintenance Assistance
Payments
In-Placement Administrative Costs Case Planning and Management
In-Placement Administrative Costs Eligibility Determinations
In-Placement Administrative Costs Provider Management
In-Placement Administrative Costs Agency Management
Total In-Placement
Administrative Costs
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

$

$

$

$

$

$

$

$

$

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$

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$

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$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

SACWIS Operational Costs
SACWIS Developmental Costs:
Project 1 - APD Required
SACWIS Developmental Costs:
Project 2 - APD Required
SACWIS Developmental 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 25c

$

$

$

$

$

$

$

$

$

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Total Costs

$

$

$

$

$

$

11
12
13
14
15
16
17
18
19
20
TRIBES

Non-Federal (State or Tribal)
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
50% FFP rate for all cost categories, except
where noted

21
22
STATES

23
24
25
26
27

Adoption Assistance
Payments (FMAP rate)
Tribal/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 25c

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

$

$

$

$

$

$

$

$

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$

28
Total Costs

29
30
TRIBES

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

$

$

$

$

$

$

Form CB- 496 [Part 1 - Page 1 of 2] (10/01/2013) Replaces 10/01/2010 version.

DRAFT - MAY 2013

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

OMB APPROVED
Control No. 0970-0205
Expires XX/XX/2016

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES (Including Caseload Data)
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

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

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

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

31

Guardianship Assistance
Payments (FMAP rate)
32 Tribal/State Agreement Guard Assist
STATES Payments (Applicable FMAP Rate)
33 Administrative Costs Agency
34 Administrative Costs Non-Recurring
35 Training Costs - Staff
(75% FFP Rate)
36 Train. Costs - Relative Guardian and
Prof Partner (Transitional FFP Rate)
37a Demonstration Project Costs From Part 3, Line 25c
37b Post Demonstration Guardianship
STATES Assistance and Services Costs

$

$

$

$

$

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$

38
Total Costs

39
40
TRIBES

Non-Federal (State or Tribal)
Share 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 Funded Candidate Administrative Costs.

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
STATES

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] (10/01/2013) Replaces 10/01/2010 version.

Date:

102510

DRAFT - MAY 2013

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

OMB APPROVED Control
No. 0970-0205 Expires
XX/XX/2016

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:

(A) Total
Adjustment

(B) Federal Share
of Adjustment

(C) Funding
Category *

SECTION A: INCREASING ADJUSTMENTS
$

$

$

$

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SECTION B: DECREASING ADJUSTMENTS

Mark
Box:

(D) Applicable to
Fiscal Quarter Ended

Initial Report
Revised Report

(E) Adjustment Identification and Explanation
(if applicable)

<=== TOTAL INCREASING ADJUSTMENTS

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

* Funding Category Codes - See form instructions for a complete list of applicable funding codes.
* Funding Categories:

(with equivalent line numbers from Part 1):

FPY
FPA
FAC
FAE
FAM
FAA

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

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)

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)

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)

FSN

SACWIS Development Costs - Non APD (Line 14)

GAN

Guardianship Admin - Non-Recurring (Line 34)

FTS

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

GTS

Guardianship Training Costs - Staff (Line 35)

FTP

Foster Care Training Costs - Professional Partners (Line 16)

GTP

Guardianship Training Costs - Professional Partners (Line 36)

FDE

Foster Care Demo Project Costs (Line 17)

GPD

Guardianship Post-Demo Project Costs (Line 37)

Form CB-496 [Part 2]

(10/01/2013) Replaces 10/01/2010 version.