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Enclosure 1

OMB No. 0980-0130
Approved through 9/30/83

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

State: Agency: Section A: Estimate of Expenditures for the Calendar Quarter Beginning:

through

(Month)

(Day)

(Year)

(Month)

(Day)

(Year)

	Non-Voluntary Foster Care (a)	Voluntary Foster Care (b)	Adoption Assistance (c)
1. Average Monthly Number of Eligible Children for Whom Payments Will Be Made in Quarter: Payments - Computable Amounts Only:
2. Total Computable Amounts
3. Federal Share Training Expenditures - Computable Amounts:
4. Total Computable Amounts
5. Federal Share Administrative Expenditures- Computable Amounts:
6. Total Computable Amounts
7. Federal Share

Section B: Selection and Control of Title IV-E Foster Care

Allotment 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 section 474(b); or
   / / (b)	Paragraph (3)(C) of that section for eligible States.	$

   
   
   

2. Total FFP claimed for Non-Voluntary
   and Voluntary Foster Care
   (payments, administration and
   training) for the following periods:

   a)	First quarter of the fiscal year	$
   b)	Second quarter of the fiscal year	$
   c)	Third quarter of the fiscal year	$

   
   
   
3. Total FFP estimated for Non-Voluntary

   and Voluntary Foster Care (payments, administration and training) for the fourth quarter of the fiscal year.

   $

4. Balance of foster care allotment

   available for this fiscal year.

   $

5. 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:

Dated:

INSTRUCTION FOR COMPLETING:

Quarterly Estimate of Expenditures for Foster Care and Adoption Assistance under Title IV, Part E of the Social Security Act. (Form No.: IV-E-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.
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 of the Act and the implementing 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, regulation and policy, without regard to the amount of the allotment limitation.
Line 3:	For all columns, multiply the Total Computable Amount on Line 2 by the Federal Medical Assistance Percentage (FMAP).
Line 4:	Enter allowable costs for this program under the approved cost allocation plan and 45 CFR 1356.60, 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 1356.60, 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 shares.

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 to the amount calculated under paragraph (3)(C) of that section. However, no State selecting (b) may transfer funds not needed for foster care under their allotment to Title IV-B (Line 5 of this section).
Lines 2(a), (b), & (c):	Enter the total claims for all activities (payments, training and administration for non-voluntary and voluntary foster care) for the current fiscal year. Include claims for adjustments for this fiscal year. Do not include those adjustments for prior years. Footnote amounts that are estimated for any quarter.
Line 3:	Enter the total estimate for all activities (payment.s, training and administration for non-voluntary and voluntary foster care) for the fourth quarter of the current fiscal year.
Line 4.	From Line 1, subtract Lines 2 (a), (b) and (c) and Line 3. The result is the amount available for the remainder of the fiscal year for further awards, positive adjustments, and transfer to title IV-B, subject to the limitations of section 474(c) of the Act.
Line 5:	Enter the amount, if any, to be transferred to title IV-B and used for child welfare services. A revised CWS-101 (budget request) must be completed and the use of the funds described in a jointly developed amendment to the title IV-B plan. Only States meeting the requirements of section 427 of the Act and the implementing regulations may transfer funds. Transfer funds must be obligated for title IV-B expenditures during the current fiscal year.

Amounts, Signature, and Date on Certification

The amounts appropriated or made available by the State and its political subdivisions for all the specified programs/activities during the quarter should be mutually exclusive and must exclude any Federal funds granted or State and local funds used to match Federal funds for any other program and purpose. In the space provided at the bottom of this form, there should appear the original signature of the authorized official of the State Agency, together with his official title, and the date the estimate is submitted. Only the original needs to be hand signed. The signing of the estimate will serve as certification by the State agency that the information contained in the form has been carefully prepared and presents as realistic an estimate of the expenditures to be incurred as possible and an accurate statement of the State and local funds available for the period of the estimate.

Complete and send the original statement forty-five (45) days before the beginning of the quarter for which funds are requested to:

Financial Management Division Children's Bureau P.0. Box 1182 Washington, D.C. 20013

Send one copy of the form to the appropriate Regional Program Director for Children, Youth and Families at the same time.

Enclosures

Enclosure 2 - Revised Form IV-E-2 with instructions
Enclosure 3 - Comparison between old and revised Form IV-E-2