U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES -- ADMINISTRATION FOR CHILDREN AND FAMILIES

CHILD CARE AND DEVELOPMENT FUND ACF-696 FINANCIAL REPORT

STATE

FISCAL YEAR

SUBMISSION (MARK ONE BOX)

CURRENT QTR. ENDED:

GRANT DOCUMENT #

ORIGINAL [    ] REVISED [     ]

FINAL [    ]

NEXT QTR. BEGINNING:

CUMULATIVE FISCAL YEAR TOTALS

(COLUMN A)

MANDATORY FUNDS

(Federal Share Only)

(COLUMN B)

MATCHING FUNDS

AT FMAP RATE  OF__________% (Federal and State Share)

(COLUMN C)

DISCRETIONARY FUNDS

(Federal Share Only)

(COLUMN D)

MOE

(State Share Only)

1.  TOTAL

$

$

$

$

     1(a). CHILD CARE ADMINISTRATION

$

$

$

$

     1(b). QUALITY ACTIVITIES NOT INCLUDED IN EARMARKS

$

$

$

$

     1(c). EARMARK TO INFANT AND TODDLER

$

     1(d). EARMARK TO QUALITY EXPANSION

$

     1(e). EARMARK TO SCHOOL-AGE/RESOURCE AND REFERRAL

$

     1(f). OTHER EARMARKED FUNDS

$

     1(g).  DIRECT SERVICES

$

$

$

$

     1(h).  NONDIRECT SERVICES

$

$

$

$

               1(h)(1). SYSTEMS

$

$

$

$

               1(h)(2). CERTIFICATE PROGRAM COSTS/ELIG.

                            DETERMINATION

$

$

$

$

               1(h)(3).  ALL OTHER NONDIRECT SERVICES

$

$

$

$

2. STATE SHARE OF EXPENDITURES

$

$

     2(a). REGULAR

$

$

     2(b). PRIVATE DONATED FUNDS

$

$

     2(c). PRE-K

$

$

3. FEDERAL SHARE OF EXPENDITURES

$

$

$

4. FEDERAL SHARE OF UNLIQUIDATED OBLIGATIONS

$

$

$

5. AWARDED

$

$

$

6. TRANSFER FROM TANF

$

7. UNOBLIGATED BALANCE

$

$

$

8. FEDERAL FUNDS REQUESTED
ESTIMATES FOR NEXT QTR.  (Refer to Next Qtr. Beginning Date Above.)

$

$

$

PLEASE REFER TO REALLOTTED FUNDS INFORMATION ON PAGES 5 OF THE INSTRUCTIONS.

9/30 SUBMITTAL -- IF AVAILABLE, DOES THE STATE REQUEST REALLOTTED MATCHING FUNDS?             YES [     ]   NO   [     ]. IF YES AND THE STATE REQUESTS A LIMIT TO THE MATCHING AMOUNT, PLEASE ENTER AMOUNT  $ _______________

3/31 SUBMITTAL -- IF AVAILABLE, DOES THE STATE REQUEST REALLOTTED DISCRETIONARY FUNDS?   YES [ ]   NO [     ].

THIS IS TO CERTIFY THAT THE INFORMATION REPORTED ON ALL PARTS OF THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

THIS ALSO CERTIFIES THAT THE STATE'S SHARE OF ESTIMATES IS OR WILL BE AVAILABLE TO MEET THE NONFEDERAL SHARE OF EXPENDITURES AS REQUIRED BY LAW.

SIGNATURE: STATE OFFICIAL

APPROVED OMB CONTROL NO. 0970-0163

TYPED NAME, TITLE, AGENCY NAME, PHONE #

DATE SUBMITTED:

EXPIRATION DATE: 12/31/2003

FORM ACF-696  PAGE 1 OF 1

* FOR LINES 1(c), 1(d), 1(e) AND 1(f), ATTACH A SEPARATE PAGE THAT INCLUDES A BRIEF DESCRIPTION OF THE ACTIVITIES ON WHICH EARMARKED FUNDS, FROM THE FISCAL YEAR'S GRANT, WERE EXPENDED.  THIS NEED ONLY BE COMPLETED WITH EACH 4TH QUARTER'S REPORT.