Form 34 OCSS-34

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Overview

OCSS 34 Part 1
OCSS 34 Part 2

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Sheet 1: OCSS 34 Part 1

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES																																			OMB APPROVED.
Office of Child Support Services																																			Control No. 0970-0510
																																			Expires: XX/XX/XXXX
FORM OCSS-34: CHILD SUPPORT SERVICES PROGRAM QUARTERLY COLLECTION REPORT
PART 1: COLLECTIONS RECEIVED, DISTRIBUTED and UNDISTRIBUTED
State/Tribe:										Quarter Ended:															Mark Box:
																									Initial Report					Revised Report
SECTION A. AVAILABLE COLLECTIONS																																(G) Total
1.	Balance Remaining Undistributed at End of Last Quarter (Carried from Line 9b, Part 1 of Previous Quarter)…………….…....…																													$
2.	Collections Received During the Quarter…………………………………..…………………………………………………………………………..																													$
		2a.	From Offset of													2e.	From IV-D & Non-IV-D
			Federal Tax Refund.................................................						$								Income Withholding......................................................						$
		2b.	From Offset of													2f.	From
			State Tax Refund.......................................................................						$								Other States or Tribes....................................................						$
		2c.	From Offset of													2g	From
			Unemployment Comp...........................................................						$								Other Countries……….....						$
		2d.	Through Administra-													2h	From
			tive Enforcement......................................						$								Other Sources..............						$
3.	Net Amount of Increasing and (Decreasing) Adjustments..................................................................................................																													$
4.	Collections Sent During the Quarter Outside the Reporting State's IV-D Program…………………………….……………………																													$
						(A) Current IV-A Assistance				(B) Current IV-E Assistance				(C) Former IV-A Assistance				(D) Former IV-E Assistance				(E) Medicaid Never Assist.				(F) Other Never Assistance				(G) Total
4a	Sent to Non IV-D
STATES	Families………………………																													$
4b.	Sent to Other
	States or Tribes.............................					$				$				$				$				$				$				$
4c.	Sent to Other
	Countries……………………………																													$
5.	(Reserved)
6.	Remaining Collections Available for Distribution……………………………………………………………………………………………																													$
SECTION B. DISTRIBUTED / UNDISTRIBUTED COLLECTIONS																																(G) Total
7a.	Collections
	Passed Through……………..					$				$				$				$												$
7b.	Dist As Assistance
	Reimbursement………...…					$				$				$				$												$
7c.	Dist As Medical
	Support……………………..					$				$				$				$				$				$				$
7d.	Distributed To
	Family or FC……………					$				$				$				$				$				$				$
7e.	Fees Withheld
STATES	by State ……………..									$								$				$				$				$
8.	Total
	Distributed...............................					$				$				$				$				$				$				$
9.	Gross Undistributed Collections.....………………….………….............................................................................................																													$
9a.	Undistributed Collections Determined Undistributable and Abandoned…………………………...…………………………………………………………																													$
9b.	Net Undistributed Collections (Report on Line 1, Part 2) (Carry forward to Line 1, Part 1, Next Quarter)…………………...…….…………………………………………………………………..																													$
SECTION C. FEDERAL SHARE / FEES																																(G) Total
10a.	Fed Share of
STATES	IV-E Collect………………									$								$												$
10b.	Fed Share of
STATES	IV-A Collect………………					$								$																$
11.	Fees Retained by Other States…………………………………………………..……………………………………………………………..																													$
This certifies that the information on this form is accurate and true to the best of my knowledge and belief.
Signature, IV-D Agency Director																		Signature, Approving Official
												Date:																	Date:
Typed Name, Title, Agency																		Typed Name, Title, Agency
Form OCSS-34 - Part 1 (06/01/2021)														Unchanged from 10/01/2014 version.

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Sheet 2: OCSS 34 Part 2

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES																																		OMB APPROVED.
Office of Child Support Services																																		Control No. 0970-0510
																																		Expires: XX/XX/XXXX
FORM OCSS-34: CHILD SUPPORT SERVICES PROGRAM QUARTERLY COLLECTION REPORT
PART 2: ITEMIZED UNDISTRIBUTED COLLECTIONS
(Completion Optional for Tribes)
State/Tribe:												Quarter Ended:												Mark Box:
																								Initial Report					Revised Report
1	Net Undistributed Collections - (from Line 9b, Part 1, of this report) ……………………...………...…
	(Also equal to the sum of Lines 2 and 8 and the sum of Lines 14 through 20, below.)																												$
SECTION A: NET UNDISTRIBUTED COLLECTIONS BY CATEGORY
2	Portion of Net Undistributed Collections Pending Distribution……………………………………………..........																												$
	The amount in Item 2 must equal the sum of the amounts in Items 3 through 7. Attach any explanatory comments.
	3	Collections Received Within The Past Two Business Days….....................................................…………….......................																											$
	4	Collections From Tax Offsets Being Held for Up To Six Months.............................………………………….......……….																											$
	5	Collections Received and Being Held for Future Support.....................................................................................																											$
	6	Collections Being Held Pending the Resolution of Legal Disputes...........................................................................																											$
	7	Collections Being Held Pending Transfer to Other State or Federal Agency.............................................................																											$
8	Portion of Net Undistributed Collections Unresolved……………………………………………………….................																												$
	The amount in Item 8 must equal the sum of the amounts in Items 9 through 13. Attach any explanatory comments.
	9	Unidentified Collections........................................................................................................................................																											$
	10	Collections Being Held Pending the Location of the Custodial or Non-Custodial Parent..................................................																											$
	11	Collections Disbursed but Uncashed and Stale-Dated.................................................................................................................																											$
	12	Collections With Inaccurate or Missing Information.....................................................................................................																											$
	13	Other Collections Remaining Undistributed.........................................................................................................																											$
SECTION B: NET UNDISTRIBUTED COLLECTIONS BY AGE
	14	Collections Remaining Undistributed Up to 2 Business Days of Receipt…………………..……………………………………																											$
	15	Collections Remaining Undistributed More Than 2 Days, But Not More Than 30 Days……………….…………..																											$
	16	Collections Remaining Undistributed More Than 30 Days, But Not More Than 6 Months……………..……….………																											$
	17	Collections Remaining Undistributed More Than 6 Months, But Not More Than 1 Year…………………...…………….																											$
	18	Collections Remaining Undistributed More Than 1 Year, But Not More Than 3 Years…………………...……………																											$
	19	Collections Remaining Undistributed More Than 3 Years, But Not More Than 5 Years…………..………...………..																											$
	20	Collections Remaining Undistributed More Than 5 Years…...........................................................................……																											$
Form OCSS-34 - Part 2 (06/01/2021)														Unchanged from 10/01/2014 version.