Form CB-496 Quarterly Financial Report

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

Control No. 0970-0205
Expires: 08/31/2016

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

Current (Claiming) Quarter
Ended:

Reporting Periods
Next (Estimating) Quarter
Ending:

Mark
Box:

Report Type
Initial Report
Rev'd Report

SECTION A: FOSTER CARE PROGRAM
50% FFP rate for all cost categories,
except where noted
1
Maintenance Assistance
Payments (FMAP Rate)
2
Tribal-State Agreement Maint. Assist.
STATES Payments (Applicable FMAP Rate)
3
Federal Share of Child Support
STATES Collections (From Form OCSE-34A)
4
Net Maintenance Assistance
Payments
5
In-Placement Administrative Costs Case Planning and Management
6
In-Placement Administrative Costs Eligibility Determinations
7
In-Placement Administrative Costs Provider Management
8
In-Placement Administrative Costs Agency Management
9
Total In-Placement
Administrative Costs
10a
Candidate Administrative
Costs - Pre-Placement Activities
10b
Human Trafficking
Administrative Costs
11
SACWIS Operational
Costs
12
SACWIS Developmental Costs Project 1 -APD Required
13
SACWIS Developmental Costs Project 2 - APD Required
14
SACWIS Developmental Costs No APD Required
15
Training Costs - Staff and Provider
(75% FFP Rate)
16
Training Costs - Professional
Partner (Transitional FFP Rate)
17
Demonstration Project Costs
(From Part 3, Line 25c)
18
Total Costs

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

Prior Quarter Adjustment Claims
(C) Total
(D) Fed Share

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

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

19

Non-Federal (State or Tribal) Share
of Total Costs
20
Tribal Share of Costs from
TRIBES Third Party In-Kind Sources

$

$

$

$

$

$

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

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

Adoption Assistance
Payments (FMAP Rate)
22
Tribal-State Agreement Adopt. Assist.
STATES Payments (Applicable FMAP Rate)
23
Administrative Costs Agency
24
Administrative Costs Non-Recurring
25
Training Costs - Staff and Provider
(75% FFP Rate)
26
Training Costs - Professional
Partner (Transitional FFP Rate)
27
Demonstration Project Costs
(From Part 3, Line 25c)
28
Total Costs
Non-Federal (State orTribal) Share of
of Total Costs
30
Tribal Share of Costs from
TRIBES Third Party In-Kind Sources

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

29

$

$

$

$

$

$

Form CB-496 [Part 1 - Page 1 of 2] (10/01/2015) Replaces 10/01/2013 version.

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

Control No. 0970-0205
Expires: 08/31/2016

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES (Including Caseload Data)
Reporting Periods
Current (Claiming) Quarter
Next (Estimating) Quarter
Ended:
Ending:

State/Tribe:

Mark
Box:

Report Type
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
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
Training Costs - Relative Guardian &
Prof. Partner (Transitional FFP Rate)
37a Demonstration Project Costs
(From Part 3, Line 25c)
37b Post-Demonstration Guardianship
STATES Assistance and Services Costs
38
Total Costs

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

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

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

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

39

Non-Federal (State or Tribal) Share of
of Total Costs
40
Tribal Share of Costs from
TRIBES 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
44a
44b

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
Number of Children:
Title IV-E Funded Human Trafficking 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 Expenses

GUARDIANSHIP ASSISTANCE PROGRAM
48

Number of Children:
Title IV-E Assistance Payments
49
Number of Children:
Any Assistance Payments
50
Number of Children:
Title IV-E Non-Recurring Administrative Cost Expenses
51
Number of Children:
STATES Title IV-E Post Demonstration Guardianship 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] (10/01/2015) Replaces 10/01/2013 version.

Date:

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

Control No. 0970-0205
Expires: 08/31/2016

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.)

Foster Care

Applicable Program:
State/
Tribe:

Adoption Assistance

Guardianship Assistance

Current (Claiming)
Quarter Ended:

(A) Total
Adjustment

(B) Federal Share
of Adjustment

(C) Funding
Category*

SECTION A: INCREASING ADJUSTMENTS
$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

SECTION B: DECREASING ADJUSTMENTS
$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

(D) Applicable to
Fiscal Quarter Ended

Mark
Box:
(E)

Adjustment Identification
and Explanation

<=== TOTAL INCREASING ADJUSTMENTS

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

* Funding Category Codes - See form CB-496, Part 2 instructions for a complete list of applicable codes.
Form CB-496 [Part 2] (10/01/2013) Replaces 10/01/2010 version.

Initial Report
Revised Report

DRAFT - 03/26/13
U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Administration on Children, Youth and Families
Children's Bureau

OMB APPROVED
Expires: 08/31/2013

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

Project Approval Date:
Foster Care
Adoption Assistance
Guardianship Assistance
Applicable Program:
Applicable Cost Neutrality Limit (CNL) Method:
Experimental Design
Capped Allocation Design
Maintenance Assistance Payments
Administration
SACWIS Oper. Costs
Applicable Funding Category(ies):
Current (Claiming)
Quarter Ended:

State/Tribe:
Current Quarter FMAP Rate =

Next (Estimating)
Quarter Ending:

Mark
Box:

50%

Next Quarter FMAP Rate =

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

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

Total Expenditures
(E) Total

Total Expenditures
(F) Fed Share

Training
Initial Report
Revised Report

50%

Next Quarter Estimates
(G) Total
(H) Fed Share

SECTION A: TITLE IV-E ALLOWABLE AND WAIVER BASED DEMONSTRATION PROJECT COSTS
Complete either subsection I or subsection II depending on the cost neutrality method specified in the project terms & conditions for reported project.
I. Experimental Design Projects
1a
1b
2a
2b
3
4

Title IV-E Maintenance Assistance
Payments Operations (FMAP Rate)
Title IV-E Adminisration (All Applicable Categories)
Operations (50% FFP Rate)
FMAP Rate - Project Intervention and
Other Waiver Based Expenditures
50% FFP Rate - Project Intervention and
Other Waiver Based Expenditures
Project Developmental
Costs (50% FFP Rate)
Project Evaluation
Costs (50% FFP Rate)

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

II. Capped Allocation Projects
5a
5b
5c
5d
5e
6a
6b
6c
7
8

Title IV-E Maintenance Assistance
Payments Operations (FMAP Rate)
Title IV-E In-Placement Administration (Excluding
Candidate) Operations (50% FFP Rate)
Title IV-E Candidate Administration
Operations (50% FFP Rate)
Title IV-E SACWIS Operational Cost
Operations (50% FFP Rate)
Title IV-E Staff/Provider & Prof. Partner
Training Operations (75% FFP Rate)
FMAP Rate - Project Intervention and
Other Waiver Based Expenditures
50% FFP Rate - Project Intervention and
Other Waiver Based Expenditures
75% FFP Rate - Project Intervention and
Other Waiver Based Expenditures
Project Developmental
Costs (50% FFP Rate)
Project Evaluation
Costs (50% FFP Rate)

III. All Program Projects
9
10

Total Demonstration Project
Operational Costs
Total Demonstration Project
Developmental/Evaluation Costs

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

SECTION B: COST NEUTRALITY (Complete either subsection I or subsection II based on the cost neutrality method specified in the project terms & cond. for the project.)
I. Experimental Design Projects
11a Maint. Pymts. (FMAP Rate) - Cumulative Exp.
Group Title IV-E Cost Neutrality Limit (CNL)
11b Admin. Costs (50% FFP Rate) - Cumulative Exp.
Group Title IV-E Cost Neutrality Limit (CNL)
12a FMAP Rate - Currently Rptd. & Cumulatively
Funded Exper. Group & Other Oper. Costs
12b 50% FFP Rate - Currently Rptd. & Cumulatively
Funded Exper. Group & Other Oper. Costs
13a FMAP Rate -Cumulative Experimental Group &
Other Oper Costs In Excess of CNL
13b 50% FFP Rate - Cumulative Experimental
Group & Other Oper Costs In Excess of CNL
14a FMAP Rate - Fundable Portion of
Total Quarterly Project Operational Costs
14b 50% FFP Rate - Fundable Portion of
Total Quarterly Project Operational Costs
15a FMAP Rate - Non-Fundable Portion of
Total Quarterly Project Operational Costs
15b 50% FFP Rate - Non-Fundable Portion of
Total Quarterly Project Operational Costs
16a FMAP Rate - Cumulative Holding Account
(Unfunded Operational Costs In Excess of CNL)
16b 50% FFP Rate - Cumulative Holding Account
(Unfunded Operational Costs In Excess of CNL)

Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->

$

-

Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->

$

-

Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->

II. Capped Allocation Projects
17a Maintenance Payments (FMAP Rate) Cumulative Title IV-E Capped Allocation (CA)

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

17b Admin. & SACWIS Costs (50% FFP Rate) -

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

Cumulative Title IV-E Capped Allocation (CA)
Training Costs (75% FFP Rate) Cumulative Title IV-E Capped Allocation (CA)
18a FMAP Rate -Currently Rptd. & Cumulatively
Funded Demonstration Operational Costs
17c

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

18b 50% FFP Rate - Currently Rptd. & Cumulatively
Funded Demonstration Operational Costs
18c

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

75% FFP Rate -Currently Rptd. & Cumulatively

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

Funded Demonstration Operational Costs
19a FMAP Rate - Cumulative Demonstration
Operational Costs In Excess of CA

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

19b 50% FFP Rate - Cumulative Demonstration
Operational Costs In Excess of CA
19c

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

75% FFP Rate - Cumulative Demonstration

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

Operational Costs In Excess of CA
20a FMAP Rate - Fundable Portion of
Total Quarterly Project Operational Costs
20b 50% FFP Rate - Fundable Portion of
Total Quarterly Project Operational Costs
20c

75% FFP Rate - Fundable Portion of
Total Quarterly Project Operational Costs

21a FMAP Rate - Non-Fundable Portion of
Total Quarterly Project Operational Costs
21b 50% FFP Rate - Non-Fundable Portion of
Total Quarterly Project Operational Costs
21c

75% FFP Rate - Non-Fundable Portion of
Total Quarterly Project Operational Costs

(Unfunded Operational Costs In Excess of CA)

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

75% FFP Rate - Cumulative Holding Account
(Unfunded Operational Costs In Excess of CA)

$

-

22b 50% FFP Rate - Cumulative Holding Account
22c

-

$

22a FMAP Rate - Cumulative Holding Account
(Unfunded Operational Costs In Excess of CA)

$

Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->

SECTION C: PROJECT SAVINGS/UNUSED ALLOCATIONS
Complete either subsection I or subsection II depending on the cost neutrality method specified in the project terms & conditions for reported project.
I. Experimental Design Projects
Savings: Estimated
(E) Total
23a

FMAP Rate - Title IV-E Savings
Remaining Available For Expenditure

23b

50% FFP Rate - Title IV-E Savings
Remaining Available For Expenditure

II. Capped Allocation Projects
24a FMAP Rate - Cumulative Title IV-E Capped
Allocation Remaining Available For Expenditure
24b 50% FFP Rate - Cumulative Title IV-E Capped
Allocation Remaining Available For Expenditure
24c

75% FFP Rate - Cumulative Title IV-E Capped
Allocation Remaining Available For Expenditure

Savings: Actual

Savings: Estimated

(F) Fed Share

(H) Agency Share

$

-

$

-

$

-

$

-

$

-

$

-

Unused Alloc.: Actual

Unused Alloc.: Est.

Unused Alloc.: Est.

(E) Total

(F) Fed Share

(H) Agency Share

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

SECTION D: FUNDABLE CLAIMS/ESTIMATES
25a
25b
25c

Experimental Design
Projects Subtotal
Capped Allocation Design
Projects Subtotal
All Program
Projects Total

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

(H) Agency Share

25d IV-E Agency Share of All Program Projects
Total Estimates
Form CB-496 [Part 3] (10/01/2013) Replaces 10/01/2010 version.

$

-

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES

Control No. 0970-0205

Administration on Children, Youth and Families

Expires: 08/31/2016

Children's Bureau

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 4: ANNUAL ADOPTION SAVINGS CALCULATION AND ACCOUNTING REPORT
(Attach this report to Part 1 for the current quarter ended September 30th of each year.)
State/Tribe:
Calculation Methodolgy Used:

X

Reporting Period: Current

Current FFY FMAP Rate =

Mark

Initial Report

Federal Fiscal Year (FFY):

Prior FFY FMAP Rate =

Box:

Rev'd Report

Children's Bureau Method

Alternate Approved Method

Actual Amounts

SECTION A: ADOPTION SAVINGS CALCULATION
Line #
1

Reporting Line Title

(A) Current FFY

(B) Prior Reported
FFYs - As Specified by
Instructions

Prior Reported FFYs - Total Cumulative Calculated Adoption Assistance
Applicable Child Savings (All Categories)

2

(C) Total

$

-

$

-

$

-

$

-

Average Monthly Number of Children: Current FFY & Prior FFY
Title IV-E Adoption Assistance Payments Solely Due to "Applicable Child" Status

3

Adoption Assistance Payments (Total)
On Behalf of Line 2 Applicable Children

4

Calculated Adoption Assistance Payments Applicable Child Savings
On Behalf of Line 2 Applicable Children (FMAP Rate Federal Share of Line 3)

5

$

-

$

-

Adoption Assistance Adminuistration (Total)
On Behalf of Line 2 Applicable Children

6

Calculated Adoption Assistance Administration Applicable Child Savings
On Behalf of Line 2 Applicable Children (50% FFP Rate Federal Share of Line 5)

7

On Behalf of Line 2 Applicable Children
8

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

Total Calculated Adoption Assistance Applicable Child Savings (All Categories)
Cumulative Total Calculated Adoption Assistance Applicable Child Savings
(All Categories) Available For Expenditure (lines 1 + 7)

SECTION B: ADOPTION SAVINGS EXPENDITURES
9

Prior Reported FFYs - Total Cumulative Expenditures of Calculated
Adoption Assistance Applicable Child Savings (line 1 amount)

10

FFY Expenditures of Adoption Assistance Applicable Child Savings
On Post-Adoption or Post-Guardianship Services (from line 8 amount)

11

FFY Expenditures of Adoption Assistance Applicable Child Savings
On Foster Care Avoidance Permanency Support Services (from line 8 amount)

12

FFY Expenditures of Adoption Assistance Applicable Child Savings
On Other Title IV-B or Title IV-E Allowable Services (from line 8 amount)

13

FFY - Total Expenditures of Calculated
Adoption Assistance Applicable Child Savings (lines 10 + 11 + 12)

14

$

-

$

-

$

-

$

-

$

-

$

-

$

-

$

-

Cumulative - Total Expenditures of Calculated
Adoption Assistance Applicable Child Savings (lines 9 + 13)

SECTION C: UNEXPENDED ADOPTION SAVINGS
15

Prior Reported FFYs - Unexpended Balance of Calculated
Adoption Assistance Applicable Child Savings (line 1 - line 9)

16

Current FFY - Unexpended Balance of Calculated
Adoption Assistance Applicable Child Savings (line 7 - line 13)

17

$

-

$

-

$

-

$

-

$

-

$

-

Cumulative - Unexpended Balance of Calculated
Adoption Assistance Applicable Child Savings (line 15 + line 16)

This certifies that the information on Part 4 of this form is accurate and true to the best of my knowledge and belief.
This also certifies that the ecpenditures identified in Section B consist of non-federal funds which supplement, not supplant, any federal or non-federal funds used to provide
any service under titles IV-B or IV-E.

Signature, Approving Official

Typed Name, Title, Agency
Form CB-496 [Part 4] (10/01/20xx)

Date: