ࡱ>  @ Nbjbjצצ v!Mo  8!!| $ """"|L($RU `""`` ""ĺĺĺ` " "ĺ`ĺĺ G "{% _v7wD%0 ?q"qS q S$vTĺܸD @ Ğ MONTHLY REPORT ON FOSTER CARE UNDER THECountyFAMILY DIVISION OF THE CIRCUIT COURT FORMTEXT      Michigan Department of Human ServicesReporting Period (Month & Year) FORMTEXT      NOTE: See non-discrimination & PA 431 information on Page 3. SECTION A: Children provided care, total days care provided under the jurisdiction of the Family Division of the Circuit Court, and expenditures by order of the family court judge of probate from the Child Care Fund. Line (1) Type of Care (2) Number of Children (3) Days Care Provided (4) Gross Expenditures (5) Adjustments.1/ (6)Adjusted Reimbursable Expenditures (7)1.III. FAMILY FOSTER CARE2. A. Court Supervised3. 1. Family Foster Care payments  FORMTEXT     FORMTEXT    $ FORMTEXT      $ FORMTEXT      $ FORMTEXT      4. 2. Other (non-scheduled) payments XXXXXX FORMTEXT       FORMTEXT       FORMTEXT      5. B. Private Agency6. 1. Family Foster Care payments  FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      7. 2. Other (non-scheduled) payments XXXXXX FORMTEXT       FORMTEXT       FORMTEXT      8.TOTAL FAMIY FOSTER CARE(Sum of lines 3 & 6 for col. 3 & 4 and sum of lines 3, 4,6 and 7 for col. 5, 6 & 7)  FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      9.II. INSTITUTIONAL CARE10. A. Court Operated11. 1. Detention  FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      12. 2. Group Care Facility  FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      13. 3. Shelter Care Facility  FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      14. 4. Other FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       (Specify)  FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      15. B. Another County s Institution (Court or DSS)16. 1. Institutional Care payments  FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      17. 2. Other (non-scheduled) payments XXXXXX FORMTEXT       FORMTEXT       FORMTEXT      18. C. Private Institution19. 1. Institutional Care payments  FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      20. 2. Other (non-scheduled) payments XXXXXX FORMTEXT       FORMTEXT       FORMTEXT      21.TOTAL INSTITUTIONAL CARE(Sum of lines 11-14, 16 and 19 for col. 3 & 4 andsum of lines 11-14, 16, 17, 19 and 20 for col. 5, 6 & 7)  FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      22.III. TOTAL IN-HOME CARE (Total from Column 4, line 8 of the IHC Addendum DHS-2396-A)  FORMTEXT    XXX FORMTEXT       FORMTEXT       FORMTEXT       .1/ Includes debit and credit correction transfers (Journal entry corrections of over or under reported expenditures or revenue). Line (1) Type of Care (2) Number of Children (3) Days Care Provided (4) Gross Expenditures (5) Adjustments.1/ (6)Adjusted Reimbursable Expenditures (7)23.IV. INDEPENDENT LIVING24. A. Per Diem [payments  FORMTEXT     FORMTEXT    $ FORMTEXT      $ FORMTEXT      $ FORMTEXT      25. B. 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J L N ~ jDh*Ujеh*Uj\h*Ujh*Ujh*UmHnHujh*Ujh*U h*5h*CJOJQJh*?|~B!*!!!O!!!!!6!!"!!!!^!B!*!! dd$$If$d$$If]a$Ff-$d$$Ifa$ -d$$If  .02Z!O!!!!!6!!"!!!!^!!B!*!!!O!! dd$$If$d$$If]a$Ff-$d$$Ifa$ -d$$IfZ\^`bdfhjlnprtvxz|~!!!6!!"!!!!^!!B!*!!!O!!!!Ff-$d$$Ifa$ dd$$If$d$$If]a$Ff -d$$If. 0 2 !6!!"!!!!^!!B!*!!!O!!!!6!!$d$$If]a$Ff-$d$$Ifa$ -d$$If dd$$If2 4 6 8 : < > @ B D F H J L N P ~ "!!!!^!!B!*!!!O!!!!!6!!"!!! dd$$If$d$$If]a$Ff-$d$$Ifa$ -d$$If~ !! !!"!$!&!0!2!4!6!8!!@!B!D!F!H!J!L!!^!!B!*!!!O!!!!!6!!"!!!!^!! dd$$If$d$$If]a$Ff%-$d$$Ifa$ -d$$IfL!N!P!R!T!V!X!Z!\!^!1"2"3"4"B!*!!!O!!!X9D[X9v:u5kd$$Ifl490:4 laf4$If5kdb$$Ifl490:4 laf4$IfFf -d$$If 4"5"6"7"8"="A"B"C"P"T"U"_"h"l"m"w""""""X9v: $$Ifa$5kd$$Ifl490:4 laf4$If"""""""""" $$Ifa$ """""WE!4!'6! -d$$If dd$$If$d$$If]a$kdO$$Ifl4֞.^&09~~   4 laf4"""""""""""###### #!# $ $$!"!!!!^!!B!*!!!O!!!!!6!"!! dd$$If$d$$If]a$Ff -d$$If-$d$$Ifa$$2$4$8$`$b$f$$$$$$$$$%% % %%%%!!^!!B!*!!!O!!!!!6!!"!!!!^! dd$$If$d$$If]a$Ff -d$$If-$d$$Ifa$0$8$:$N$P$R$\$^$f$h$|$~$$$$$$$$$$$$$$$%%.%0%2%<%>%D%F%Z%\%^%h%j%r%t%%%%%%%%%%%%%%&&&&jPh*Ujh*Ujhh*U h*5h*CJOJQJjh*Ujh*Ujh*UmHnHujh*Ujh*Uh*:%@%B%D%l%n%r%%%%%%%%%%%%%%%%!B!*!!!O!!!!!6!!"!!!!^!!B!*! dd$$If$d$$If]a$Ff -d$$If-$d$$Ifa$%%%%%%%%%%&&&&& & &&&&&&!!O!!!!!6!!!!!^!!B!*!!!O! dd$$If$d$$If]a$Ff -d$$If-$d$$Ifa$&&&&&&&&&&&&&&&&&&&&&&!!!!6!!"!!!!^!!B!*!!!O!!!Ff dd$$If$d$$If]a$Ff -d$$If-$d$$Ifa$&&&&&&&&&&&&&&'' '''''.'0'2'<'>'D'F'Z'\'^'h'j'p'r'''''''''''''(,(.(0(((((((((jxh*Ujh*Ujh*Uj&h*Ujh*UmHnHujh*Ujh*U h*5h*CJOJQJh*:&&&&&&&'''@'B'D'l'n'p'''''!!6!!"!!!!^!!B!*!!!O!!!!Ff-$d$$Ifa$ -d$$If dd$$If$d$$If]a$'''''''''''''''''''(((!6!!"!!!!^!!B!*!!!O!!!!6!!$d$$If]a$Ff-$d$$Ifa$ -d$$If dd$$If(((((( ("($(&(((*(,(.(0(2((((((("!!!!^!!B!*!!!O!!!!!6!!"!!! dd$$If$d$$If]a$Ff -$d$$Ifa$ -d$$If(((((((((((((((((())):)!^!!B!*!!!O!!!!!6!!"!!!!^!! dd$$If$d$$If]a$Ff-$d$$Ifa$ -d$$If((((((())) ) )))()*),)6)8)>)@)T)V)X)b)d)j)l))))))))))))))*ڹڮڤڟڤڟڝژڤڟ h*5EH h*>*U h*5h*CJOJQJjh*Uj,h*Ujh*UjNh*Uh*jh*UmHnHujh*Ujh*U5:)<)>)f)h)j)))))))))))))))))B!*!!!O!!!!!6!!"!!!!^!!B!*!! dd$$If$d$$If]a$Ff-$d$$Ifa$ -d$$If)))))))))):<!O!!!j#j#j#*! $$Ifa$  d$If  $If  & F $If $$If]a$ $If] $$If]a$Ff\-$d$$Ifa$ -d$$IfF REIMBURSABLE EXPENDITURES A. Net Probate Court Ordered Collections RECEIPTS (75% of Gross Collections).2/ $ FORMTEXT      XXXXXXXXXXXXXX30. B. Government Benefit Collections  FORMTEXT      XXXXXXXXXXXXXX31. C. Other Receipts  FORMTEXT      XXXXXXXXXXXXXX32.Total Receipts Applicable to CCF Reimbursement(Sum of lines 29, 30, 31) $ FORMTEXT      33.NET EXPENDITURES SUBJECT TO (50%)REIMBURSEMENT (Line 27 less line 32)  FORMTEXT      34.FOSTER CARE DURING RELEASE APPEAL PERIOD(100% Reimbursable) Attach Court Order(s)  FORMTEXT      35.TOTAL STATE REIMBURSEMENT DUE (50% ofline 33 plus 100% of line 34)  FORMTEXT      36.NET AUDIT ADJUSTMENT (INDICATE PLUS ORMINUS ) Within current Fiscal YearSpecify Month(s)  FORMTEXT      37.TOTAL STATE REIMBURSEMENT(Sum of line 35, plus or ,minus line 36)  FORMTEXT      38.Enter in the space provided the number of days care in out-of-state placements: Family Foster Care (Lines 3 and 6, col. 3) FORMTEXT      ; Institutional (Line 19, col. 3) FORMTEXT      . .1/ Includes debit and credit correction transfers (Journal entry corrections of over or under reported expenditures or revenue). .2/ 25% may be deferred to offset costs of court ordered collection and deposited in the General Fund.SECTION B: Expenditures made under the Basic Grant program as authorized by Section 117e of Act 87, PA 1978. Participating County(s)  If report is for Joint Basic Grant list all Participating Counties. FORMTEXT       FORMTEXT       Line (1) Service Component (Specify/Identify Component) (2) Total Grant Amount (3) Current Month Expenditures (4)Expenditures Fiscal Year To Date (5) Balance (Col. 3  Col. 5) (6)43. FORMTEXT      $ FORMTEXT      $ FORMTEXT      $ FORMTEXT      $ FORMTEXT      44. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      45. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      46. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      47. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      48. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      49. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      50.GRAND TOTAL  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      SECTION C:CERTIFICATION: I certify that (to the best of my knowledge and belief) the data contained in these reports are correct and in accord with the instructions and definitions established by the Department of Human Services for this report; that this is a correct statement of expenditures and that the net reimbursable expenditures represent no cost for capital outlay. Appropriate documentation is available and will be maintained to support costs reported.Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.Family Court Judge (Signature)DateAUTHORITY: P.A. 280 of 193 and Section 117 E of Act 87 of P.A. 1978.COMPLETION: Voluntary DHS-207 (Rev. 9-05) Previous edition may be used. 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