Form 34 OCSS-34

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

form ocss_34_2021_name chg 2024.xlsx

Child Support Services Program Financial Reporting Forms (OCSS-34 and OCSS-396)

OMB: 0970-0510

Document [xlsx]
Download: xlsx | pdf

Overview

OCSS 34 Part 1
OCSS 34 Part 2


Sheet 1: OCSS 34 Part 1

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES

































OMB APPROVED.
Office of Child Support Services

































Control No. 0970-0510



































Expires: XX/XX/XXXX
FORM OCSS-34: CHILD SUPPORT SERVICES PROGRAM QUARTERLY COLLECTION REPORT
PART 1: COLLECTIONS RECEIVED, DISTRIBUTED and UNDISTRIBUTED




































State/Tribe:








Quarter Ended:













Mark Box:

































Initial Report



Revised Report








































SECTION A. 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 Administra-











2h 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 (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






4a Sent to Non IV-D

































STATES Families………………………























$




4b. Sent to Other


































States or Tribes.............................



$


$


$


$


$


$


$




4c. Sent to Other


































Countries……………………………























$








































5. (Reserved)





































































6. Remaining Collections Available for Distribution……………………………………………………………………………………………



























$








































SECTION B. DISTRIBUTED / UNDISTRIBUTED COLLECTIONS






























(G) Total


7a. Collections


































Passed Through……………..



$


$


$


$










$




7b. Dist As Assistance


































Reimbursement………...…



$


$


$


$










$




7c. Dist As Medical


































Support……………………..



$


$


$


$


$


$


$




7d. Distributed To


































Family or FC……………



$


$


$


$


$


$


$




7e. Fees Withheld

































STATES by State ……………..







$






$


$


$


$




8. Total


































Distributed...............................



$


$


$


$


$


$


$








































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. FEDERAL SHARE / FEES






























(G) Total


10a. Fed Share of

































STATES IV-E Collect………………



$






$










$




10b. Fed Share of

































STATES IV-A Collect………………



$






$














$








































11. 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, IV-D Agency Director















Signature, Approving Official
































































Date:















Date:





Typed Name, Title, Agency
















Typed Name, Title, Agency
























































































Form OCSS-34 - Part 1 (06/01/2021)












Unchanged from 10/01/2014 version.





















Sheet 2: OCSS 34 Part 2

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
































OMB APPROVED.
Office of Child Support Services
































Control No. 0970-0510


































Expires: XX/XX/XXXX
FORM OCSS-34: CHILD SUPPORT SERVICES 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 OCSS-34 - Part 2 (06/01/2021)












Unchanged from 10/01/2014 version.



















File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy