396 Ocss-396

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES Office of Child Support Services

OMB APPROVED Control No. 0970-0510 Expires: 06/30/2024

FORM OCSS-396: CHILD SUPPORT SERVICES PROGRAM QUARTERLY FINANCIAL REPORT PART 1: EXPENDITURES and ESTIMATES

State:

Current (Claiming) Quarter Ended:

Next (Estimating) Quarter Ending:

Mark Initial Report Box: Rev'd Report

66% FFP rate for all cost categories, except where noted

Current Quarter Claims

Prior Quarter Adjustments

Next Quarter Estimate

(A) Total

(B) Federal Share

(C) Total

(D) Federal Share

(E) Total

(F) Federal Share

SECTION A. EXPENDITURES

1a. Admin. Costs w/ Incentive Payments (No FFP)

$

$

$

$

$

$

1b. Administrative Costs: Regular

$

$

$

$

$

$

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:

From Form OCSS-34 Line 10b, Col G ==>

$

$

10. Fees - Federal FPLS:

Enter Total Fee in Column B ===>

$

11. Fees - CSENet:

Enter Total Fee in Column B ===>

$

12. Fees - Pre-Offset Service:

Enter Total Fee in Column B ===>

$

13. Adjustments:

Enter Total Amount in Column B ===>

$

14. Net Federal Share of Expenditures:

$

$

$

15. State Share of Expenditures:

Enter State Share Only in Column B ===>

$

Enter State Share Only in Column D ===>

$

$

SECTION C. 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 Date:

Signature, Approving Official Date:

Typed Name, Title, Agency

Typed Name, Title, Agency

Form OCSS-396 - Part 1 (06/01/2021)

Unchanged from 10/01/2017 version

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES Office of Child Support Services

OMB APPROVED Control No. 0970-0510 Expires: XX/XX/XXXX

FORM OCSS-396: CHILD SUPPORT SERVICES PROGRAM QUARTERLY FINANCIAL REPORT PART 2: PRIOR QUARTER EXPENDITURE ADJUSTMENTS

State:

Current (Claiming) Quarter Ended:

Mark Box:

Initial Report Revised Report

(A) Total Adjustment

(B) Federal Share of Adjustments

(C) Funding Category

(D) Applicable to Fiscal Quarter Ended

(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 OCSS-396 - Part 2 (06/01/2021)

Unchanged from 10/01/2014 version