Form 34 OCSE-34

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-34: CHILD SUPPORT ENFORCEMENT PROGRAM QUARTERLY COLLECTION REPORT
PART 1: COLLECTIONS RECEIVED, DISTRIBUTED and UNDISTRIBUTED
State/Tribe:

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
Federal Tax Refund...... $
Income Withholding...... $
2b. From Offset of
2f. From
State Tax Refund.......... $
Other States or Tribes...$
2c. From Offset of
2g From
Unemployment Comp... $
Other Countries……….. $
2d. Through Administra2h From
tive Enforcement........ $
Other Sources.............. $

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
STATES

4b.
4c.

Sent to Non IV-D
Families……………
Sent to Other
States or Tribes...... $
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.
7a.
STATES

7b.
7c.
7d.
7e.
STATES

8.

DISTRIBUTED / UNDISTRIBUTED COLLECTIONS

Collections
Passed Through………$
Dist As Assistance
Reimbursement………$
Dist As Medical
Support…………………$
Distributed To
Family or FC………… $
Fees Withheld
by State ……………..
Total
Distributed.................. $

(G) Total

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$
$

$

$

9.

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.
10a.
STATES

10b.
STATES

11.

FEDERAL SHARE / FEES

Fed Share of
IV-E Collect……………
Fed Share of
IV-A Collect……………$

(G) Total

$

$
$

$
$

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, Approving Official

Signature, IV-D Agency Director
Date:
Typed Name, Title, Agency

Form OCSE-34 - Part 1 (10/01/2017)

Date:
Typed Name, Title, Agency

Unchanged from 10/01/2014 version.

mhb

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-34: CHILD SUPPORT ENFORCEMENT PROGRAM QUARTERLY COLLECTION REPORT
PART 2: ITEMIZED UNDISTRIBUTED COLLECTIONS
(Completion Optional for Tribes)
State/Tribe:

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-34 - Part 2 (10/01/2017)
Unchanged from 10/01/2014 version.

mhb