CB-496 Quarterly Financial Report

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

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

DRAFT - MAY 2013

Children's Bureau

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 3: DEMONSTRATION PROJECTS (Attach this Report to Part 1)
Project Approval Date:

Applicable Program:
Foster Care
Applicable Cost Neutrality (CNL) Method:

Applicable Funding Category(ies):

Adoption Assistance
Experimental Design

Maintenance Assistance Payments

Administration

Current (Claiming)
Quarter Ended:

State/Tribe:
50% FFP rate for all cost categories,
except where noted

Guardianship Assistance
Capped Allocation Design
SACWIS Operational Costs

Next (Estimating)
Quarter Ending:

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

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

Total Expenditures
(E) Total

Training

Mark
Box:
Total Expenditures
(F) Fed Share

Initial Report
Revised Report

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.
1a
1b
2a
2b

I. Experimental Design Projects
Title IV-E Maintenance Assistance
Payments Operations (FMAP Rate)
Title IV-E Administration
(All Applicable Categories) Operations
Project Intervention and Other
Waiver Based Expenditures (FMAP Rate)
Project Intervention and Other
Waiver Based Expenditures (50% FFP Rate)

3

Project Developmental Costs
4

Project Evaluation Costs

5a
5b
5c
5d
5e
6a
6b
6c

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

8

10

$

-

$

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$

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$

$

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-

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$

-

Positive Claims, FMAP Rate, Col F --->

$

Positive Claims, 50% FFP Rate, Col F --->

$

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$

-

$

Project Evaluation Costs

9

-

$

7

III. All Program Projects
Total Demonstration Project
Operational Costs
Total Demonstration Project
Developmental/Evaluation Costs

$

Positive Claims, FMAP Rate, Col E --->

$

Positive Claims, 50% FFP Rate, Col E --->

$

Positive Claims, 50% FFP Rate, Col E --->

$

$

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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.)
11a
11b
12a
12b
13a
13b
14a
14b
15a
15b
16a
16b

17a
17b
17c
18a
18b
18c
19a
19b
19c
20a
20b
20c
21a
21b
21c
22a
22b
22c

I. Experimental Design Projects
Maint. Pymts. - Cumulative Expenditures.
Group Cost Neutrality Limit (CNL) (FMAP Rate)
Admin. Costs - Cumulative Expenditures.
Group Cost Neutrality Limit (CNL)
Currently Reported & Cumulatively Funded
Exper. Group & Other Oper. Costs (FMAP Rate)
Currently Reported & Cumulatively Funded
Exper Group & Other Oper Costs (50% FFP Rate)
Cumulative Experimental Group & Other
Oper Costs In Excess of CNL (FMAP Rate)
Cumulative Experimental Group & Other
Oper Costs In Excess of CNL (50% FFP Rate)
Fundable Portion of Total Quarterly
Project Operational Costs (FMAP Rate)
Fundable Portion of Total Quarterly
Project Operational Costs (50% FFP Rate)
Non-Fundable Portion of Total Quarterly
Project Operational Costs (FMAP Rate)
Non-Fundable Portion of Total Quarterly
Project Operational Costs (50% FFP Rate)
Cumulative Holding Account (Unfunded Oper
Costs In Excess of CNL) (FMAP Rate)
Cumulative Holding Account (Unfunded Oper
Costs In Excess of CNL) (50% FFP Rate)
II. Capped Allocation Projects
Maintenance Payments (FMAP Rate) Cumulative Title IV-E Capped Allocation (CA)
Admin. & SACWIS Costs
Cumulative Title IV-E Capped Allocation (CA)
Training Costs (75% FFP Rate) Cumulative Title IV-E Capped Allocation (CA)
Currently Reported & Cumulatively Funded
Demonstration Operational Costs (FMAP Rate)
Currently Reported & Cumulatively Funded
Demonstration Operational Costs (50% FFP Rate)
Currently Reported & Cumulatively Funded
Demonstration Operational Costs (75% FFP Rate)
Cumulative Demonstration Operational
Costs In Excess of CA (FMAP Rate)
Cumulative Demonstration Operational
Costs In Excess of CA (50% FFP Rate)
Cumulative Demonstration Operational
Costs In Excess of CA (75% FFP Rate)
Fundable Portion of Total Quarterly
Project Operational Costs (FMAP Rate)
Fundable Portion of Total Quarterly
Project Operational Costs (50% FFP Rate)
Fundable Portion of Total Quarterly
Project Operational Costs (75% FFP Rate)
Non-Fundable Portion of Total Quarterly
Project Operational Costs (FMAP Rate)
Non-Fundable Portion of Total Quarterly
Project Operational Costs (50% FFP Rate)
Non-Fundable Portion of Total Quarterly
Project Operational Costs (75% FFP Rate)
Cumulative Holding Account (Unfunded Oper
Costs In Excess of CA) (FMAP Rate)
Cumulative Holding Account (Unfunded Oper
Costs In Excess of CA) (50% FFP Rate)
Cumulative Holding Account (Unfunded Oper
Costs In Excess of CA) (75% FFP Rate)

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 -->

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

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

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

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

Title IV-E Savings Remaining Available
For Expenditure (FMAP Rate)
23b Title IV-E Savings Remaining Available
For Expenditure (50% FFP Rate)
23a

#DIV/0!
$

II. Capped Allocation Projects
Cumulative Title IV-E Capped Allocation (CA)
Remaining Available For Expenditure (FMAP Rate)
24b Cumulative Title IV-E Capped Allocation (CA)
24a

Remaining Available For Expenditure (50% FFP Rate)
24c

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

-

Savings: Actual

Savings: Estimated

(F) Fed Share

(H) Agency Share

$

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Unused Alloc.: Actual

Unused Alloc.: Est.

(E) Total

(F) Fed Share

#DIV/0!
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Unused Alloc.: Est.
(H) Agency Share

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SECTION D: FUNDABLE CLAIMS/ESTIMATES
25a

#DIV/0!

Experimental Design Projects Subtotal
25b

Capped Allocation Design Projects Subtotal
25c

All Program Projects Total

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(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

#DIV/0!