Form No, IV-E (or IV-A-FC)-1
Department of Health and Human Services
Office of Human Development Services
Administration for Children, Youth and Families
Quarterly Estimate of Expenditures for Foster Care and Adoption Assistance Under Title IV, Part E or Part A (Foster Care only) of the Social Security Act.
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State: Agency: Section A: Estimate of Expenditure for the Calendar Quarter beginning through (Month) (Day) (Year) (Month) (Day) (Year) |
| Non-voluntary Foster Care (a) |
Voluntary Foster Care (b) |
Adoption Assistance (c) |
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1. Average Monthly Number of Payments - Computable Amounts |
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| 2. Total Computable Amounts | |||
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3. Federal Share Training Expenditures - |
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| 4. Total Computable Amounts | |||
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5. Federal Share Administrative Expenditures - |
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| 6. Total Computable Amounts | |||
| 7. Federal Share |
Section B: Selection and Control of Foster Care Allotment (Title IV-E or IV-A) and Transfer of Funds (Non-voluntary and Voluntary Foster Care)
1. Foster care allotment limitation for this fiscal year:
(Select (a) or (b)
| Federal Share $ Only | |
|
/ / (a) Paragraph (3)(A) or (3)(B) of / / (b) Paragraph (3)(C) of that section |
$ |
| 2. Funds awarded previously for this fiscal year for foster care (exclude adjustments for prior fiscal years). |
$ |
| 3. Funds requested in this estimate request (Sum of (3)(a) and (b), 5(a) and (b), and 7(a) and (b) of Section A). |
$ |
| 4. Balance of adjustments for this fiscal year reported since last award |
$ |
| 5. Balance of : expenditures for this fiscal year reported since last award compared to estimate funds awarded for that same quarter |
$ |
| 6. Balance of foster care allotment available for this fiscal year |
$ |
| 7. For eligible States only, funds to be transferred to title IV-B for Child Welfare Services. (Submit revised CWS-101 for title IV-B and submit amendment to jointly - developed title IV-B Plan) |
$ |
I certify that the above estimated expenditures for operation of the State's approved plan for the quarter are based on the most reliable information available to the State.
I further certify that the State and local funds available for the quarter indicated are:
| State: $ | Local: $ |
(The signature of the State Administrator on this form will be acceptable as certification that these funds are available to meet the non-Federal share of the estimates. For States in which the State Administrator is not considered to have authority to certify to the availability of State funds, this item must be left blank, and a certification by the appropriate State officials attached.)
| Signed: Title: |
Date: |
INSTRUCTION FOR COMPLETING
Quarterly Estimate of Expenditures for Foster Care and Adoption Assistance under Title IV, Part E or Part A (Foster Care only) of the Social Security Act. (Form No. IV-E(or IV-A-FC)-1).
Heading Section
Complete the heading section of the report entering the name of the State and the agency.
| Section A: | Enter the beginning and ending dates of the calendar quarter for which estimate payments are requested. |
| Column (a) | Each State must complete this column regardless of whether it is operating its Foster Care Program under Part E or Part A. |
| Column(b) | Only States requesting Federal financial participation (FFP) for voluntary (agency) placements need complete this column. In order to receive such FFP, a State must meet all the conditions of sections 427(b) and 472 or 408 of the Act and the implementation regulations. |
| Column (c) | Only States with an approved Title IV-E plan may seek FFP (for adoption assistance). |
| Line 1: | Enter the number of children who will receive any payment for any period of time during each month for which a payment is made during the quarter reported on (line c of heading). A child for whom payments are made in each of the three months must be entered for each month. Divide the total for the 3 months of the calendar quarter by 3. These numbers are necessary for determining State allotments. |
| Line 2: | Enter the amount of dollars computable or subject to Federal matching for estimated expenditures allowable under Federal law, regulations and policy, without regard to the amount of the allotment limitation. |
| Line 3: | For States reporting under Title IV-E, for all columns multiply the Total Computable Amount on Line 2 by the Federal Medical Assistance Percentage (FMAP). For States reporting under Title IV-A, use either the FMAP or the formula under section 403(a) of the Act. |
| Line 4: | Enter allowable costs for this program under the approved cost allocation plan and 45 CFR 205.150, without regard to the amount of the allotment limitation. |
| Line 5: | Multiply the amounts on Line 4 by 75%, the rate of Federal Financial Participation (FFP). |
| Line 6: | Enter allowable costs for this program under the approved cost allocation plan and 45 CFR 205.150, without regard to the amount of the allotment limitation. |
| Line 7: | Multiply the amounts on Line 6 by 50%,the rate of Federal Financial Participation (FFP). |
Section B:
General - This section must be completed no later than as a part of the estimate report for Fourth Quarter. It may be completed as part of earlier estimate reports . Enter only the Federal share. It applies in the same way to Foster Care under Title IV-E and IB-A.
| Line 1: | Select either (a) or (b) and enter the appropriate amount. Each State will be entitled to the higher of the allotment under paragraph (3)(A) or (3)(B) of section 474 of the Act. Some States may be eligible (under paragraph (5) of section 474(b) of the Act) under the formula for paragraph (3)(C) of that section. However, no State selecting (b) may transfer funds not used for foster care under their allotment to Title IB-B (Line 7 of this section). The allotments are Federal share amounts. |
| Line 2: | Enter the Federal awards for all activities (payments, training and administration for non-voluntary and voluntary foster care) for the current fiscal year. Include estimate amounts paid, balances from expenditure claims, and balances from adjustments for this fiscal year that were incorporated in those awards. Do not include those portions of the awards paid for adjustments to prior years. |
| Line 3: | Enter the total of estimates of expenditures reported as items 3(a) and (b), 5(a) and (b) and 7(a) and (b) of Section A of this report (estimates for the next quarter), without regard to the amount of the allotment limitation. |
| Line 4: | Enter the balance of adjustments for this fiscal year claimed since the last award (Column (b) of expenditure reports), without regard to the amount of the allotment limitation. A positive balance should be entered as a positive amount and a negative balance as a negative amount. |
| Line 5: | Enter the balance of expenditures reported since the last award and the estimate amount we awarded for that same quarter, without regard to the allotment limitation. When this section (B) is completed as part of the first and second quarter estimate reports, Line 5 will be left blank. As part of the third quarter estimate report, Line 5 will be the positive or negative balance of the expenditures compared to the paid estimate for the first quarter. As part of the fourth quarter estimate report, Line 5 will be the balance of expenditures compared to the paid estimate for the second quarter. Expenditures greater than estimates will result in a positive balance. |
| Line 6: | From Line 1, subtract Lines 2 and 3. Subtract Line 4 and/or Line 5 if positive balances; add Line 4 and/or Line 5 if negative balances. The result is the amount available for the remainder of the fiscal year for further awards, positive adjustments, and transfer over to Title IV-B or the amount by which the allotment limitation would be exceeded. |
Attachments:
Attachment 1 - Program Instruction
Attachment 3 - IV-E (or IV-A-FC)-2 (Quarterly Statement of Expenditures)
