CB-496 Mandatory Grant Submission Template

Request for Approval under the “Generic Clearance for the Collection of Mandatory Grant Financial Reports” (OMB Control Number: 0970-0510) Expiration date 5/31/2021

TITLE OF INFORMATION COLLECTION:

Form CB-496 - Title IV-E Programs Quarterly Financial Report

PURPOSE:

The information collected through the use of this form is used to:

• Monitor title IV-E Foster Care, Adoption Assistance, Guardianship Assistance, Kinship Navigator and Prevention Services program operations and prepare technical assistance and guidance as needed;

• Compute the quarterly grant awards pursuant to sections 474(b)(1-3) and 474(a)(5-7) of the Social Security Act;

• Account for the calculation and expenditure of adoption savings achieved through the use of revised title IV-E Adoption Assistance eligibility criteria with respect to applicable children (annual report only).

DESCRIPTION OF RESPONDENTS:

State and tribal governmental agencies administering title IV-E programs.

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

BURDEN HOURS

Title of Information Collection	No. of Respondents	Annual Frequency of Responses	Hourly Burden per Response	Annual Hourly Burden
Form CB-496	67	4	25	6,700
Totals	67	4	25	6,700

FEDERAL COST: The estimated annual cost to the Federal government is: $0_________

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of Respondents.

Burden per Response: Provide an estimate of the amount of time (in minutes) required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of Respondents, times Frequency times Burden per Response.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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