Form CB-496 CB Financial Report

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Overview

Part 1 - Page 1
Part 1 - Page 2
Part 1 - Page 3
Part 2
Part 3
Part 4

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Sheet 1: Part 1 - Page 1

DRAFT - Form CB-496 (All Parts) - Oct. 2018
U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Administration on Children, Youth and Families																																			Control No. 0970-0205
Children's Bureau										`																									Expires: 10/31/--------
FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES (Including Caseload Data)
									Reporting Periods																						Report Type
State/Tribe:									Current (Claiming) Quarter										Next (Estimating) Quarter										Mark		Initial Report
									Ended:										Ending:										Box:		Rev'd Report
SECTION A: FOSTER CARE PROGRAM
50% FFP rate for all cost categories, except where noted						Current Quarter Claims										Prior Quarter Adjustment Claims										Next Quarter Estimates
						(A) Total					(B) Fed Share					(C) Total					(D) Fed Share					(E) Total					(F) Fed Share
1a	Agency Maintenance (Maint.) Payments -					$					$					$					$					$					$
	Foster Family Home (FMAP Rate)
1b	Agency Maint. Payments - Specified Setting					$					$					$					$					$					$
	Child Care Institution (FMAP Rate)
1c	Agency Maint. Payments - Non-Specified Setting					$					$					$					$					$					$
	Child Care Institution (FMAP Rate)
1d	Agency Maint. Payments - Substance Abuse					$					$					$					$					$					$
	Treatment Facility (FMAP Rate)
1e	Agency Maint. Payments -					$					$					$					$					$					$
	Total (FMAP Rate)
2a	Tribal-State Agreement (Agmt.) Maint. Payments -					$					$					$					$					$					$
STATES	Foster Family Home (Applicable FMAP Rate)
2b	Tribal-State Agmt. Maint. Payments - Other					$					$					$					$					$					$
STATES	Qualifying Placements (Applicable FMAP Rate)
2c	Tribal-State Agmt. Maint. Payments -'					$					$					$					$					$					$
STATES	Total (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 and Agency Management
8	Total In-Placement					$					$					$					$					$					$
	Administrative Costs
9	Title IV-E Foster Care Candidate					$					$					$					$					$					$
	Administrative Costs - Pre-Placement Activities
10	Sex Trafficking					$					$					$					$					$					$
	Administrative Costs
11a	Non-CCWIS					$					$					$					$					$					$
	Project Operational Costs
11b	Non-CCWIS					$					$					$					$					$					$
	Project Developmental Costs
12a	CCWIS Project Operational Costs Using					$-					#VALUE!					#VALUE!					#VALUE!					#VALUE!					#VALUE!
	CCWIS Cost Allocation				Number
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
12b	CCWIS Project Operational Costs Using					$-					#VALUE!					#VALUE!					#VALUE!					#VALUE!					#VALUE!
	Non-CCWIS Cost Allocation				Number
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
13a	CCWIS Project Developmental Costs					$-					#VALUE!					#VALUE!					#VALUE!					#VALUE!					#VALUE!
	CCWIS Cost Allocation – APD Required				Number
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:										$					$					$					$					$
13b	CCWIS Project Developmental Costs Using					$-					#VALUE!					#VALUE!					#VALUE!					#VALUE!					#VALUE!
	Non-CCWIS Cost Allocation – APD Required				Number
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
Dropdown	[Project Number (e.g., NA, 01, 02, etc.]:					$					$					$					$					$					$
14a	CCWIS Project Developmental Costs Using					$					$					$					$					$					$
	CCWIS Cost Allocation – No APD Required
14b	CCWIS Project Developmental Costs Using					$					$					$					$					$					$
	Non-CCWIS Cost Allocation – No APD Required
15	Training Costs - Staff, Provider and					$					$					$					$					$					$
	Professional Partner (75% FFP Rate)
16	Demonstration Project Costs					$					$					$					$					$					$
	(From Part 3, Line 25c)
17						$					$					$					$					$					$
	Total Costs
18	Non-Federal (State or Tribal) Share										$										$										$
	of Total Costs
19	Tribal Share of Costs from										$										$										$
TRIBES	Third Party In-Kind Sources
SECTION B: ADOPTION ASSISTANCE PROGRAM
50% FFP rate for all cost categories, except where noted						Current Quarter Claims										Prior Quarter Adjustments										Next Quarter Estimates
						(A) Total					(B) Fed Share					(C) Total					(D) Fed Share					(E) Total					(F) Fed Share
20	Agency Adoption Assistance Payments					$					$					$					$					$					$
	(FMAP Rate)
21	Tribal-State Agreement Adoption Assistance					$					$					$					$					$					$
STATES	Payments (Applicable FMAP Rate)
22	Administrative Costs -					$					$					$					$					$					$
	Agency
23	Administrative Costs -					$					$					$					$					$					$
	Non-Recurring
24	Training Costs - Staff and Provider and					$					$					$					$					$					$
	Professional Partner (75% FFP Rate)
25	Demonstration Project Costs					$					$					$					$					$					$
	(From Part 3, Line 25c)
26						$					$					$					$					$					$
	Total Costs
27	Non-Federal (State or Tribal) Share of										$										$										$
	of Total Costs
28	Tribal Share of Costs from										$										$										$
TRIBES	Third Party In-Kind Sources
Form CB-496 [Part 1 - Page 1 of 2] (10/01/2018) Replaces 10/01/2015 version.

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Sheet 2: Part 1 - Page 2

DRAFT - Form CB-496 (All Parts) - Oct. 2018
U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES																																			Control No. 0970-0205
Administration on Children, Youth and Families																																			Expires: 10/31/----
Children's Bureau
FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES (Including Caseload Data)
									Reporting Periods																						Report Type
State/Tribe:									Current (Claiming) Quarter										Next (Estimating) Quarter										Mark		Initial Report
									Ended:										Ending:										Box:		Rev'd Report
SECTION C: GUARDIANSHIP ASSISTANCE PROGRAM
50% FFP rate for all cost categories, except where noted						Current Quarter Claims										Prior Quarter Adjustments										Next Quarter Estimates
						(A) Total					(B) Fed Share					(C) Total					(D) Fed Share					(E) Total					(F) Fed Share
29	Agency Guardianship Assistance					$					$					$					$					$					$
	Payments (FMAP Rate)
30	Tribal-State Agreement Guard. Assist.					$					$					$					$					$					$
STATES	Payments (Applicable FMAP Rate)
31	Administrative Costs -					$					$					$					$					$					$
	Agency
32	Administrative Costs -					$					$					$					$					$					$
	Non-Recurring
33	Training Costs - Staff, Provider and					$					$					$					$					$					$
	Professional Partner (75% FFP Rate)
34a	Demonstration Project Costs					$					$					$					$					$					$
	(From Part 3, Line 25c)
34b	Post-Demonstration Guardianship					$					$					$					$					$					$
STATES	Assistance and Services Costs
35						$					$					$					$					$					$
	Total Costs
36	Non-Federal (State or Tribal) Share of										$										$										$
	of Total Costs
37	Tribal Share of Costs from										$										$										$
TRIBES	Third Party In-Kind Sources
SECTION D: PREVENTION SERVICES AND KINSHIP NAVIGATOR PROGRAMS
50% FFP rate for all cost categories, except where noted						Current Quarter Claims										Prior Quarter Adjustments										Next Quarter Estimates
						(A) Total					(B) Fed Share					(C) Total					(D) Fed Share					(E) Total					(F) Fed Share
38	Prevention Services Provision - Well-Supported					$					$					$					$					$					$
	Practices
39	Prevention Services Provision - Other Qualifying					$					$					$					$					$					$
	Practices
40	Prevention Services Administrative Costs -					$					$					$					$					$					$
	Prevention Planning and Agency Management
41	Prevention Services Training Costs -					$					$					$					$					$					$
	Prevention Service Providers (50% FFP Rate)
42	Prevention Services Program -					$					$					$					$					$					$
	Total Costs
43	Prevention Services Program - Non-Federal										$										$										$
	(State or Tribal) Share of Total Costs
44	Kinship Navigator Program -					$					$					$					$					$					$
	Provision of Services
45	Kinship Navigator Program -					$					$					$					$					$					$
	Administrative Costs
46	Kinship Navigator Program -					$					$					$					$					$					$
	Total Costs
47	Kinship Navigator Program - Non-Federal										$										$										$
	(State or Tribal) Share of Total Costs
Form CB-496 [Part 1 - Page 2 of 3] (10/01/2018) Replaces 10/01/2015 version.

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Sheet 3: Part 1 - Page 3

DRAFT - Form CB-496 (All Parts) - Oct. 2018

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES

Control No. 0970-0205

Administration on Children, Youth and Families

Expires: 10/31/----

Children's Bureau

FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT

PART 1: EXPENDITURES and ESTIMATES (Including Caseload Data)

Reporting Periods

Report Type

State/Tribe:

Current (Claiming) Quarter

Next (Estimating) Quarter

Mark

Initial Report

Ended:

Ending:

Box:

Rev'd Report

SECTION E: AVERAGE MONTHLY NUMBER OF CHILDREN ASSISTED

Actual Count Current Quarter

Estimated Count Next Quarter

FOSTER CARE PROGRAM

48a

Number of Children In-Placement:

Title IV-E Maintenance Payments - Foster Family Home

48b

Number of Children In-Placement:

Title IV-E Maintenance Payments - Specified Setting Child Care Institution

48c

Number of Children In-Placement:

Title IV-E Maintenance Payments - Non-Specified Setting Child Care Institution

48d

Number of Children In-Placement:

Title IV-E Maintenance Payments - Substance Abuse Treatment Facility

49

Number of Children In-Placement:

Title IV-E Funded Administrative Costs In All Placement Settings

50

Total Number of Children In-Placement:

Any Payments or Administrative Costs In All Placement Settings

51

Number of Children Pre-Placement:

Title IV-E Funded Candidate Administrative Costs

52

Number of Children In-Placement, Care or Supervision Receiving:

Title IV-E Funded Sex Trafficking Administrative Costs

ADOPTION ASSISTANCE PROGRAM

53

Number of Children:

Title IV-E Assistance Payments

54

Total Number of Children:

Any Assistance Payments

55

Number of Children:

Title IV-E Non-Recurring Administrative Cost Expenses

GUARDIANSHIP ASSISTANCE PROGRAM

56

Number of Children:

Title IV-E Assistance Payments

57

Total Number of Children:

Any Assistance Payments

58

Number of Children:

Title IV-E Non-Recurring Administrative Cost Expenses

59

Number of Children:

STATES

Title IV-E Post Demonstration Guardianship Assistance or Services

PREVENTION SERVICES AND KINSHIP NAVIGATOR PROGRAMS

60

Number of Children:

Title IV-E Prevention Services -Any Services Provided

61

Number of Families:

Kinship Navigator Program - Any Services Provided

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

Date:

Form CB-496 [Part 1 - Page 3 of 3] (10/01/2018) Replaces 10/01/2015 version.

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Sheet 4: Part 2

DRAFT - Form CB-496 (All Parts) - Oct. 2018

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES

Control No. 0970-0205

Administration on Children, Youth and Families

Expires: 10/31/----

Children's Bureau

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.)

Applicable Program:

Foster Care

Adoption Assistance

Guardianship Assistance

Prevention Services

Kinship Navigator

State/

Current (Claiming)

Mark

Initial Report

Tribe:

Quarter Ended:

Box:

Revised Report

(A) Total

(B) Federal Share

(C) Funding

(D) Applicable to

(E)

Adjustment Identification

Adjustment

of Adjustment

Category*

Fiscal Quarter Ended

and Explanation

SECTION A: INCREASING ADJUSTMENTS

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

<=== TOTAL INCREASING ADJUSTMENTS

SECTION B: DECREASING 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] (10/01/2018) Replaces 10/01/2015 version.

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Sheet 5: Part 3

	DRAFT - Form CB-496 (All Parts) - Oct. 2018
	U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES																																									OMB APPROVED
	Administration on Children, Youth and Families																																									Expires: 10/31/----=
	Children's Bureau
	FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT
	FORM CB-496: TITLE IV-E PROGRAMS QUARTERLY FINANCIAL REPORT																																													Control No. 0970-0205
	PART 3: DEMONSTRATION PROJECTS																																													Expires: 10/31/2018
	(Attach this report to Part 1.)
	Project Approval Date:
				Applicable Program:							Foster Care									Adoption Assistance											Guardianship Assistance
	Applicable Cost Neutrality Limit (CNL) Method:														Experimental Design													Capped Allocation Design
	Applicable Funding Category(ies):							Maintenance Assistance Payments																	Administration									CCWIS Oper. Costs									Training
	State/Tribe:									Current (Claiming)																	Next (Estimating)												Mark			Initial Report
										Quarter Ended:																	Quarter Ending:												Box:			Revised Report
				Current Quarter FMAP Rate =								50%																				Next Quarter FMAP Rate =										50%
							Current Quarter Claims										Prior Quarter Adjustments										Total Expenditures					Total Expenditures					Next Quarter Estimates
							(A) Total					(B) Fed Share					(C) Total					(D) Fed Share					(E) Total					(F) Fed Share					(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	Title IV-E Maintenance Assistance										$-															$-					$-										$-
		Payments Operations (FMAP Rate)
	1b	Title IV-E Administration (All Applicable Categories)										$-										$-					$-					$-										$-
		Operations (50% FFP Rate)
	2a	FMAP Rate - Project Intervention and										$-															$-					$-										$-						Total Positive Claims
		Other Waiver Based Expenditures																																														FMAP Col. F	$-
	2b	50% FFP Rate - Project Intervention and										$-										$-					$-					$-										$-
		Other Waiver Based Expenditures																																														50% FFP Col. F	$-
	3	Project Developmental										$-										$-					$-					$-										$-
		Costs (50% FFP Rate)
	4	Project Evaluation										$-										$-					$-					$-										$-
		Costs (50% FFP Rate)
	II. Capped Allocation Projects
	5a	Title IV-E Maintenance Assistance										$-															$-					$-										$-
		Payments Operations (FMAP Rate)
	5b	Title IV-E In-Placement Administration (Excluding										$-										$-					$-					$-										$-
		Candidate) Operations (50% FFP Rate)
	5c	Title IV-E Candidate Administration										$-										$-					$-					$-										$-
		Operations (50% FFP Rate)
	5d	Title IV-E CCWIS Operational Cost										$-										$-					$-					$-										$-
		Operations (50% FFP Rate)
	5e	Title IV-E Staff/Provider & Prof. Partner										$-										$-					$-					$-										$-
		Training Operations (75% FFP Rate)
	6a	FMAP Rate - Project Intervention and										$-															$-					$-										$-						Total Positive Claims
		Other Waiver Based Expenditures																																														FMAP Col. E	$-
	6b	50% FFP Rate - Project Intervention and										$-										$-					$-					$-										$-
		Other Waiver Based Expenditures																																														50% FFP Col. E	$-
	6c	75% FFP Rate - Project Intervention and										$-										$-					$-					$-										$-
		Other Waiver Based Expenditures																																														75% FFP Col. E	$-
	7	Project Developmental										$-										$-					$-					$-										$-
		Costs (50% FFP Rate)
	8	Project Evaluation										$-										$-					$-					$-										$-
		Costs (50% FFP Rate)
	III. All Program Projects
	9	Total Demonstration Project					$-					$-					$-					$-					$-					$-					$-					$-
		Operational Costs
	10	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)																													Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
	11b	Admin. Costs (50% FFP Rate) - Cumulative Exp.
		Group Title IV-E Cost Neutrality Limit (CNL)																													Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
	12a	FMAP Rate - Currently Rptd. & Cumulatively																																								$-
		Funded Exper. Group & Other Oper. Costs																													Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
	12b	50% FFP Rate - Currently Rptd. & Cumulatively																																								$-
		Funded Exper. Group & Other Oper. Costs																													Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
	13a	FMAP Rate -Cumulative Experimental Group &																														$-										$-
		Other Oper Costs In Excess of CNL																													Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
	13b	50% FFP Rate - Cumulative Experimental																														$-										$-
		Group & Other Oper Costs In Excess of CNL																													Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
	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)																													Sum of Current Qtr and Prior Qtr Fed Share in Col. F -->
	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 -->
	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. & CCWIS Costs (50% FFP Rate) -
		Cumulative Title IV-E Capped Allocation (CA)																								Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
	17c	Training Costs (75% FFP Rate) -
		Cumulative Title IV-E Capped Allocation (CA)																								Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
	18a	FMAP Rate -Currently Rptd. & Cumulatively																																			$-
		Funded Demonstration Operational Costs																								Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
	18b	50% FFP Rate - Currently Rptd. & Cumulatively																																			$-
		Funded Demonstration Operational Costs																								Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
	18c	75% FFP Rate -Currently Rptd. & Cumulatively																																			$-
		Funded Demonstration Operational Costs																								Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
	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																								Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
	19c	75% FFP Rate - Cumulative Demonstration																									$-										$-
		Operational Costs In Excess of CA																								Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
	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
	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 -->
	22b	50% FFP Rate - Cumulative Holding Account
		(Unfunded Operational Costs In Excess of CA)																								Sum of Curr. Qtr and Prior Qtr Total Comp. in Col. E -->
	22c	75% FFP 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					Savings: Actual										Savings: Estimated
																											(E) Total					(F) Fed Share										(H) Agency Share
	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																										Unused Alloc.: Actual					Unused Alloc.: Est.										Unused Alloc.: Est.
																											(E) Total					(F) Fed Share										(H) Agency Share
	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
	SECTION D: FUNDABLE CLAIMS/ESTIMATES
	25a	Experimental Design					$-					$-					$-					$-					$-					$-					$-					$-
		Projects Subtotal
	25b	Capped Allocation Design					$-					$-					$-					$-					$-					$-					$-					$-
		Projects Subtotal
	25c	All Program					$-					$-					$-					$-					$-					$-					$-					$-
		Projects Total
																																										(H) Agency Share
	25d	IV-E Agency Share of All Program Projects																																								$-
		Total Estimates
	Form CB-496 [Part 3] (10/01/2018) Replaces 10/01/2015 version.

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Sheet 6: Part 4

DRAFT - Form CB-496 (All Parts) - Oct. 2018
							U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES																							Control No. 0970-0205
						Administration on Children, Youth and Families																								Expires: 10/31/----
	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:									Reporting Period: Current								Current FFY FMAP Rate =								Mark		Initial Report
									Federal Fiscal Year (FFY):								Prior FFY FMAP Rate =								Box:		Revised Rpt.
Calculation Methodology Used:								Children's Bureau (CB) Method								CB Method With Actual Amounts								Alternate Approved Method
SECTION A: ADOPTION SAVINGS CALCULATION
Line #	Reporting Line Title															(A) Current FFY					(B) Prior Reported FFYs - As Specified by Instructions					(C) Total
1	Prior Reported FFYs - Total Cumulative Calculated																									$-
	Adoption Savings (All Categories)
2	Average Monthly Number of Children: Current FFY & Prior FFY
	Title IV-E Adoption Assistance Payments "Applicable Child Only Status"
3	Adoption Assistance Payments (Total Computable)																									$-
	On Behalf of Line 2 Applicable Children
4	Calculated Adoption Assistance Payment Savings															$-					$-					$-
	On Behalf of Line 2 Applicable Children (FMAP Rate X Line 3)
5	Adoption Assistance Administration (Total Computable)																									$-
	On Behalf of Line 2 Applicable Children
6	Calculated Adoption Assistance Administration Savings															$-					$-					$-
	On Behalf of Line 2 Applicable Children (50% FFP Rate X Line 5)
7	Reporting Period - Total Calculated Adoption Savings (All Categories)															$-					$-					$-
	On Behalf of Line 2 Applicable Children
8	Cumulative - Total Calculated Adoption Savings															$-					$-					$-
	(All Categories) Available For Expenditure (lines 1 + 7)
SECTION B: ADOPTION SAVINGS EXPENDITURES
9	Prior Reported FFYs - Total Cumulative Expenditures of Calculated																									$-
	Adoption Savings (line 1 amount)
10	Reporting Period - Expenditures of Adoption Savings On:																									$-
	Post-Adoption or Post-Guardianship Services (from line 8 amount)
11	Reporting Period - Expenditures of Adoption Savings On:																									$-
	Services For Children At Risk of Foster Care (from line 8 amount)
12	Reporting Period - Expenditures of Adoption Savings On:																									$-
	Other Title IV-B or Title IV-E Allowable Services (from line 8 amount)
13	Reporting Period - Total Expenditures of Calculated															$-					$-					$-
	Adoption Savings (lines 10 + 11 + 12)
14	Cumulative Total Expenditures of Calculated															$-					$-					$-
	Adoption Savings (lines 9 + 13)
SECTION C: UNEXPENDED ADOPTION SAVINGS
15	Prior Reported FFYs - Unexpended Balance of Calculated																				$-					$-
	Adoption Savings (line 1 - line 9)
16	Reporting Period - Unexpended Balance of Calculated															$-					$-					$-
	Adoption Savings (line 7 - line 13)
17	Cumulative - Unexpended Balance of Calculated															$-					$-					$-
	Adoption 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 expenditures 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																					Date:
Form CB-496 [Part 4] (10/01/2018). Replaces 10/01/15 version.