Form 496 Form CB-496: Title IV-E Programs Quarterly Financial Rep

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

Form CB-496 FORM - Final Proposed Revision 02.27.20 Clean.xlsx

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

OMB: 0970-0510

Document [xlsx]
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Overview

Part 1 - Page 1
Part 1 - Page 2
Part 1 - Page 3
Part 2
Part 3 - Full Report
Part 3 - EXP
Part 3 - CAP
Part 4


Sheet 1: Part 1 - Page 1

Form CB-496 (All Parts) - OMB Approved Oct. 23, 2018

- Data Entry Permitted
































+ DRAFT February 2020



































U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES









- Calculated Through Embedded Formula
































Administration on Children, Youth and Families

































Control No. 0970-0510








Children's Bureau








`























Expires: 05/31/2021





















































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




















Current Quarter FMAP Rate =







50%
Next Quarter FMAP Rate =






51%




























































`
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 In-Placement Administrative Costs -








$-
$-



















Legal Representation - Child or Parent



























9 Total In-Placement Foster Care



$- $- $- $-
$-









Administrative Costs












10a Title IV-E Foster Care Candidate Administrative Costs -




$-
$-
$-









Case Planning and Management












10b Title IV-E Foster Care Candidate Administrative Costs -




$-
$-
$-









Legal Representation - Child or Parent












10c 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.]:

$- $ #VALUE! $ #VALUE!








Dropdown [Project Number (e.g., NA, 01, 02, etc.]:
$ #VALUE! $ #VALUE! $ #VALUE!








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.]:
$ $- $ $- $ #VALUE!








Dropdown [Project Number (e.g., NA, 01, 02, etc.]:
$ #VALUE! $ #VALUE! $ #VALUE!








Dropdown [Project Number (e.g., NA, 01, 02, etc.]:
$ #VALUE! $ #VALUE! $ #VALUE!








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.]:
$ #VALUE! $ #VALUE! $ #VALUE!








Dropdown [Project Number (e.g., NA, 01, 02, etc.]:
$ #VALUE! $ #VALUE! $ #VALUE!








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.]:
$ #VALUE! $ #VALUE! $ #VALUE!








Dropdown [Project Number (e.g., NA, 01, 02, etc.]:
$ #VALUE! $ #VALUE! $ #VALUE!








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)












16a Demonstration Project Costs



$ $ $ $ $ $









(From Part 3, Line 25c)












16b Post-Demonstration Costs



$ $ $ $ $ $









(From Part 3, Line 28a)












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.





























































































































































































































































































































































































































Sheet 2: Part 1 - Page 2

Form CB-496 (All Parts) - OMB Approved Oct. 23, 2018










- Data Entry Permitted























+ DRAFT February 2020

























Control No. 0970-0510
U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES










- Calculated Through Embedded Formula





















Expires: 05/31/2021
Administration on Children, Youth and Families



































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












Current Quarter FMAP Rate =









Next Quarter FMAP Rate =





















































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




39a Prevention Services Provision - Supported



$ $- $ $- $ $-

Practices




39b Prevention Services Provision - Promising



$ $- $ $- $ $-

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.

Sheet 3: Part 1 - Page 3

Form CB-496 (All Parts) - OMB Approved Oct. 23, 2018













- Data Entry Permitted



















+ DRAFT February 2020

























Control No. 0970-0510
U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES













- Calculated Through Embedded Formula


















Expires: 05/31/2021
Administration on Children, Youth and Families


































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























49a Number of Children In-Placement:


























Title IV-E Funded Case Planning and Management Administrative Costs























49b Number of Children In-Placement:


































Title IV-E Funded Child or Parent Legal Representation Administrative Costs

































50 Total Number of Children In-Placement:


























Any Payments or Administrative Costs In All Placement Settings























51a Number of Children Title IV-E Foster Care Candidate:


























Title IV-E Funded Case Planning and Management Administrative Costs























51b Number of Children Title IV-E Foster Care Candidate:


































Title IV-E Funded Child or Parent Legal Representation 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.

Sheet 4: Part 2


Form CB-496 (All Parts) - OMB Approved 10/23/2018















- Data Entry Permitted


























U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES


























Control No. 0970-0510







Administration on Children, Youth and Families









- Calculated Through Embedded Formula
















Expires: 05/31/2021

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.

Sheet 5: Part 3 - Full Report


Form CB-496 (All Parts) - OMB Approved 10/23/2018













- Data Entry Permitted

































U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES










































Control No. 0970-0510




Administration on Children, Youth and Families













- Calculated Through Embedded Formula



























Expires: 05/31/2021




Children's Bureau
















































+ DRAFT February 2020








































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



PART 3 (SECTIONS A-D): DEMONSTRATION PROJECTS



PART 3 (SECTIONS E-F): FOSTER CARE POST-DEMONSTRATION COSTS & FUNDING CERTAINTY GRANT CALCULATIONS



(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










Foster Care Post-Demonstration Cost Reporting:

Yes




No






















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 =



















Next Quarter FMAP Rate =














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 Adminisration (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



#DIV/0! $- $- $- #DIV/0! $- #DIV/0! $-




Total Quarterly Project Operational Costs







14b 50% FFP Rate - Fundable Portion of



$- $- $- $- $- $- $- $-




Total Quarterly Project Operational Costs







15a FMAP Rate - Non-Fundable Portion of



#DIV/0! $- $- $- #DIV/0! $- #DIV/0! $-




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























#DIV/0! $-




#DIV/0!




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



#DIV/0! $- $- $- #DIV/0! $- #DIV/0! $-




Projects Subtotal







25b Capped Allocation Design



$- $- $- $- $- $- $- $-




Projects Subtotal







25c All Program



#DIV/0! $- $- $- #DIV/0! $- #DIV/0! $-




Projects Total
















































(H) Agency Share
















































25d IV-E Agency Share of All Program Projects






































#DIV/0!




Total Estimates















































SECTION E: FOSTER CARE POST-DEMONSTRATION COSTS - FUNDING CERTAINTY GRANT CALCULATION DATA (If Applicable)



IV. Post-Demonstration Costs 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



FFY 2020 Expenditures FFY 2020 FMAP Rate =




















Next Quarter FMAP Rate =




26a FFY 2020 - Title IV-E Maintenance Assistance Payments



$- $-
$- $- $-
$-




Foster Family Home (FMAP Rate)







26b FFY 2020 - Title IV-E Maintenance Assistance Payments



$- $-
$- $- $-
$-




Specified Setting Child Care Institution (FMAP Rate)







26c FFY 2020 - Title IV-E Maintenance Assistance Payments



$- $-
$- $- $-
$-




Non Specified Setting Child Care Institution (FMAP Rate)







26d FFY 2020 -Total Title IV-E In-Placement Administration



$- $-
$- $- $-
$-




Case Planning and Management (50% FFP Rate)







26e FFY 2020 - Title IV-E Candidate Administration



$- $-
$- $- $-
$-




Case Planning and Management (50% FFP Rate)







26f FFY 2020 - Title IV-E Staff/Provider & Prof. Partner



$- $-
$- $- $-
$-




Training Costs (75% FFP Rate)







26g FFY 2020 - Subtotal Post-Demonstration



$- $-
$- $- $-
$-




Title IV-E Foster Care Costs







FFY 2021 Expenditures FFY 2021 FMAP Rate =




















Next Quarter FMAP Rate =




27a FFY 2021 - Title IV-E Maintenance Assistance Payments




$-
$- $- $-
$-




Foster Family Home (FMAP Rate)







27b FFY 2021 - Title IV-E Maintenance Assistance Payments




$-
$- $- $-
$-




Specified Setting Child Care Institution (FMAP Rate)







27c FFY 2021 - Title IV-E Maintenance Assistance Payments




$-
$- $- $-
$-




Non Specified Setting Child Care Institution (FMAP Rate)







27d FFY 2021 -Total Title IV-E In-Placement Administration




$-
$- $- $-
$-




Case Planning and Management (50% FFP Rate)







27e FFY 2021 - Title IV-E Candidate Administration




$-
$- $- $-
$-




Case Planning and Management (50% FFP Rate)







27f FFY 2021 - Title IV-E Staff/Provider & Prof. Partner




$-
$- $- $-
$-




Training Costs (75% FFP Rate)







27g FFY 2021 - Subtotal Post-Demonstration




$-
$- $- $-
$-




Title IV-E Foster Care Costs







28a Total Post-Demonstration



$- $- $- $- $- $- $- $-




Title IV-E Foster Care Costs
















































(H) Agency Share



28b Title IV-E Agency Share of Post-Demonstration






































$-




Title IV-E Foster Care Costs Total Estimates




























































































SECTION F: FUNDING CERTAINTY GRANT CALCULATIONS (If Aplicable)


















IV. Post-Demonstration Costs This Report Cumulative - All Submitted Reports Calculated Amount - All Submitted Reports Funding Certainty Grant Awards
























Total Expenditures Total Expenditures Funding Certainty Level Previously Issued Total Awards Estimated Next Annual Initial/Adjustment Award - To Date


















Title IV-E Agency Summary Data (A) Fed Share (B) Fed Share (C) Fed Share (D) Fed Share (E) Fed Share


















29 Baseline - FFY 2019 Capped Allocations












































(All funding Categories)










































30a FFY 2020 - Annual Funding Certainty Level













$-





























(90% of Baseline)










































30b FFY 2020 - Reported Title IV-E Foster Care



$-



































Post-Demonstration Costs





































30c FFY 2020 - Funding Certainty Grant













$-
$-



















Calculated Level/Awards (If Any)
































31a FFY 2021 - Annual Funding Certainty Level













$-





























(75% of Baseline)










































31b FFY 2021 - Reported Title IV-E Foster Care



$-



































Post-Demonstration Costs





































31c FFY 2021 - Funding Certainty Grant













$- $- $-



















Calculated Level/Awards (If Any)
































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













Sheet 6: Part 3 - EXP


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












- Data Entry Permitted











Form CB-496 (All Parts) - OMB Approved 10/23/2018

























U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES










































Control No. 0970-0510








Administration on Children, Youth and Families












- Calculated Through Embedded Formula




























Expires: 05/31/2021








Children's Bureau










































































































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







PART 3: DEMONSTRATION PROJECTS - EXPERIMENTAL DESIGN PROJECTS ONLY







(Attach this report to Part 1.)







Project Approval Date:












































Applicable Program:
Foster Care


Adoption Assistance









Guardianship Assistance






















Applicable Cost Neutrality Limit (CNL) Method: X 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 =



















Next Quarter FMAP Rate =


















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 Adminisration (All Applicable Categories)




$-
$- $- $-
$-








Operations (50% FFP Rate)











2a FMAP Rate - Project Intervention and




$-

$- $-
$-
Total Positive Claims Prior Quarter Adjustment Positive Claims


Other Waiver Based Expenditures




FMAP Col. F $- FMAP Col. C $- FMAP Col. D $-

2b 50% FFP Rate - Project Intervention and




$-
$- $- $-
$-








Other Waiver Based Expenditures




50% FFP Col. F $- 50% FFP Col. C $- 50% FFP Col. D $-

3 Project Developmental




$-
$- $- $-
$-








Costs (50% FFP Rate)











4 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 -->

















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




































SECTION D: FUNDABLE CLAIMS/ESTIMATES













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







25a Experimental 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 -Expl] (10/01/2018) Replaces 10/01/2015 version.

















Sheet 7: Part 3 - CAP


Form CB-496 (All Parts) - OMB Approved 10/23/2018












- Data Entry Permitted






































+ DRAFT February 2020


































Control No. 0970-0510








U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES












- Calculated Through Embedded Formula




























Expires: 05/31/2021








Administration on Children, Youth and Families




















































Children's Bureau










































































































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







PART 3 (SECTIONS A-D): DEMONSTRATION PROJECTS - CAPPED ALLOCATION DESIGN PROJECTS ONLY







PART 3 (SECTIONS E-F): FOSTER CARE POST-DEMONSTRATION COSTS & FUNDING CERTAINTY GRANT CALCULATIONS







(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
X Capped Allocation Design














Foster Care Post-Demonstration Cost Reporting:
Yes



No



























Applicable Funding Category(ies):





Maintenance Assistance Payments
Administration
CCVWIS Oper. Costs







Training







State/Tribe:
Current (Claiming)





Next (Estimating)
Mark

Initial Report











Quarter Ended:




Quarter Ending: Box:

Revised Report














Current Quarter FMAP Rate =



















Next Quarter FMAP Rate =


















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.







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 SACWIS 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 Prior Quarter Adjustment Positive Claims


Other Waiver Based Expenditures




FMAP Col. E $- FMAP Col. C $- FMAP Col. D $-

6b 50% FFP Rate - Project Intervention and




$-
$- $- $-
$-








Other Waiver Based Expenditures




50% FFP Col. E $- 50% FFP Col. C $-


6c 75% FFP Rate - Project Intervention and




$-
$- $- $-
$-








Other Waiver Based Expenditures




75% FFP Col. E $- 75% FFP Col. C $-


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.)







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. & SACWIS 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.







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













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







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




































































































SECTION E: FOSTER CARE POST-DEMONSTRATION COSTS - FUNDING CERTAINTY GRANT CALCULATION DATA (If Applicable)







IV. Post-Demonstration Costs 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







FFY 2020 Expenditures FFY 2020 FMAP Rate = 55%



















Next Quarter FMAP Rate =








26a FFY 2020 - Title IV-E Maintenance Assistance Payments




$-
$- $- $-
$-








Foster Family Home (FMAP Rate)











26b FFY 2020 - Title IV-E Maintenance Assistance Payments




$-
$- $- $-
$-








Specified Setting Child Care Institution (FMAP Rate)











26c FFY 2020 - Title IV-E Maintenance Assistance Payments




$-
$- $- $-
$-








Non Specified Setting Child Care Institution (FMAP Rate)











26d FFY 2020 -Total Title IV-E In-Placement Administration




$-
$- $- $-
$-








Case Planning and Management (50% FFP Rate)











26e FFY 2020 - Title IV-E Candidate Administration




$-
$- $- $-
$-








Case Planning and Management (50% FFP Rate)











26f FFY 2020 - Title IV-E Staff/Provider & Professional Partner




$-
$- $- $-
$-








Training Costs (75% FFP Rate)











26g FFY 2020 - Subtotal Post-Demonstration



$- $- $- $- $- $- $- $-








Title IV-E Foster Care Costs











FFY 2021 Expenditures FFY 2021 FMAP Rate =




















Next Quarter FMAP Rate =








27a FFY 2021 - Title IV-E Maintenance Assistance Payments




$-
$- $- $-
$-








Foster Family Home (FMAP Rate)











27b FFY 2021 - Title IV-E Maintenance Assistance Payments




$-
$- $- $-
$-








Specified Setting Child Care Institution (FMAP Rate)











27c FFY 2021 - Title IV-E Maintenance Assistance Payments




$-
$- $- $-
$-








Non Specified Setting Child Care Institution (FMAP Rate)











27d FFY 2021 -Total Title IV-E In-Placement Administration




$-
$- $- $-
$-








Case Planning and Management (50% FFP Rate)











27e FFY 2021 - Title IV-E Candidate Administration




$-
$- $- $-
$-








Case Planning and Management (50% FFP Rate)











27f FFY 2021 - Title IV-E Staff/Provider & Prof. Partner




$-
$- $- $-
$-








Training Costs (75% FFP Rate)











27g FFY 2021 - Subtotal Post-Demonstration



$- $- $- $- $- $- $- $-








Title IV-E Foster Care Costs











28a Total Post-Demonstration



$- $- $- $- $- $- $- $-








Title IV-E Foster Care Costs




















































(H) Agency Share







28b Title IV-E Agency Share of Post-Demonstration






































$-








Title IV-E Foster Care Costs Total Estimates




































































































SECTION F: FUNDING CERTAINTY GRANT CALCULATIONS (If Applicable)






















IV. Post-Demonstration Costs This Report Cumulative - All Submitted Reports Calculated Amount - All Submitted Reports Funding Certainty Grant Awards




























Total Expenditures Total Expenditures Funding Certainty Level Previously Issued Total Awards Estimated Next Annual Initial/Adjustment Award - To Date






















Title IV-E Agency Summary Data (A) Fed Share (B) Fed Share (C) Fed Share (D) Fed Share (E) Fed Share






















29 Baseline - FFY 2019 Capped Allocations
















































(All funding Categories)














































30a FFY 2020 - Annual Funding Certainty Level













$-

































(90% of Baseline)














































30b FFY 2020 - Reported Title IV-E Foster Care



$-







































Post-Demonstration Costs









































30c FFY 2020 - Funding Certainty Grant













$-
$-























Calculated Level/Awards (If Any)




































31a FFY 2021 - Annual Funding Certainty Level













$-

































(75% of Baseline)














































31b FFY 2021 - Reported Title IV-E Foster Care



$-







































Post-Demonstration Costs









































31c FFY 2021 - Funding Certainty Grant













$- $- $-























Calculated Level/Awards (If Any)




































Form CB-496 [Part 3 -Cap] (10/01/2018) Replaces 10/01/2015 version. 0

















Sheet 8: Part 4

Form CB-496 (All Parts) - OMB Approved 10/23/2018














- Data Entry Permitted





























U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES





















Control No. 0970-0510














Administration on Children, Youth and Families








- Calculated Through Embedded Formula












Expires: 05/31/2021









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.






































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