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pdfU.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
Office of Child Support Enforcement
OMB APPROVED
Control No. 0970-0510
Expires: 05/31/2021
FORM OCSE-396: CHILD SUPPORT ENFORCEMENT PROGRAM QUARTERLY FINANCIAL REPORT
PART 1: EXPENDITURES and ESTIMATES
State:
Current (Claiming)
Quarter Ended:
Current Quarter Claims
(A) Total
(B) Federal Share
66% FFP rate for all cost
categories, except where noted
SECTION A.
Next (Estimating)
Quarter Ending:
Mark
Box:
Prior Quarter Adjustments
(C) Total
(D) Federal Share
Initial Report
Rev'd Report
Next Quarter Estimate
(E) Total
(F) Federal Share
EXPENDITURES
1a. Admin. Costs w/ Incentive
Payments (No FFP)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
1b. Administrative Costs:
Reguar
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:
10. Fees Federal FPLS:
11. Fees CSENet:
12. Fees Pre-Offset Service:
13. Adjustments:
14. Net Federal Share of
Expenditures:
15. State Share of
Expenditures:
SECTION C.
From Form OCSE-34
Line 10b, Col G ==>
Enter Total Fee in
Column B ===>
Enter Total Fee in
Column B ===>
Enter Total Fee in
Column B ===>
Enter Total Amount in
Column B ===>
$
$
$
$
$
$
$
Enter State Share Only
in Column B ===>
$
Enter State Share Only
in Column D ===>
$
$
$
$
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
Signature, Approving Official
Date:
Typed Name, Title, Agency
Form OCSE-396 - Part 1 (10/01/2017)
Date:
Typed Name, Title, Agency
Replaces Previous Version.
mhb
U.S Department of Health and Human Services
OMB APPROVED
Office of Child Support Enforcement
Control No. 0970-0510
Expires: 05/31/2021
FORM OCSE-396: CHILD SUPPORT ENFORCEMENT PROGRAM QUARTERLY FINANCIAL REPORT
PART 2: PRIOR QUARTER EXPENDITURE ADJUSTMENTS
State:
Current (Claiming)
Quarter Ended:
(B) Federal Share of
Adjustments
(A) Total Adjustment
(C) Funding Category
(D) Applicable to Fiscal
Quarter Ended
Mark
Box:
Initial Report
Revised Report
(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 OCSE-396 - Part 2 (10/01/2017)
Unchanged from 10/01/2014 version.
mhb
File Type | application/pdf |
File Title | Form OCSE-396A (Part 1) (October 1999 version) |
Subject | Quarterly Report of Child Support Expenditures & Estimates |
Author | Michael Bratt |
File Modified | 2018-06-21 |
File Created | 2017-12-27 |