396 Ocss-396

Generic Clearance for Financial Reports used for ACF Non-Discretionary Grant Programs

form ocss_396_2021_name chg 2024.xlsx

OMB: 0970-0510

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U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Office of Child Support Services
OMB APPROVED
Control No. 0970-0510
Expires: 06/30/2024
FORM OCSS-396: CHILD SUPPORT SERVICES PROGRAM QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES
State: Current (Claiming)
Quarter Ended:
Next (Estimating)
Quarter Ending:
Mark Initial Report
Box: Rev'd Report


66% FFP rate for all cost
categories, except where noted
Current Quarter Claims Prior Quarter Adjustments Next Quarter Estimate
(A) Total (B) Federal Share (C) Total (D) Federal Share (E) Total (F) Federal Share
SECTION A. EXPENDITURES
1a. Admin. Costs w/ Incentive
Payments (No FFP)
$ $ $ $ $ $
1b. Administrative Costs:
Regular
$ $ $ $ $ $
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:
From Form OCSS-34 Line 10b, Col G ==> $


$
10. Fees -
Federal FPLS:
Enter Total Fee in Column B ===> $



11. Fees -
CSENet:
Enter Total Fee in Column B ===> $



12. Fees -
Pre-Offset Service:
Enter Total Fee in Column B ===> $



13. Adjustments: Enter Total Amount in Column B ===> $



14. Net Federal Share of
Expenditures:

$
$
$
15. State Share of
Expenditures:
Enter State Share Only
in Column B ===>
$ Enter State Share Only
in Column D ===>
$
$
SECTION C. 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

Date:
Signature, Approving Official

Date:
Typed Name, Title, Agency Typed Name, Title, Agency
Form OCSS-396 - Part 1 (06/01/2021)


Unchanged from 10/01/2017 version






























U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Office of Child Support Services
OMB APPROVED
Control No. 0970-0510
Expires: XX/XX/XXXX
FORM OCSS-396: CHILD SUPPORT SERVICES PROGRAM QUARTERLY FINANCIAL REPORT
PART 2: PRIOR QUARTER EXPENDITURE ADJUSTMENTS
State: Current (Claiming)
Quarter Ended:
Mark Box:
Initial Report
Revised Report


(A) Total Adjustment (B) Federal Share of Adjustments (C) Funding Category (D) Applicable to Fiscal Quarter Ended (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 OCSS-396 - Part 2 (06/01/2021)



Unchanged from 10/01/2014 version









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