TABLE OF CONTENTS CHAPTER 25-600 FORMS

FISCAL MANAGEMENT AND CONTROLGENERAL ADMINISTRATIVE RESPONSIBILITIESTABLE OF CONTENTSCHAPTER 25-600 FORMSSectionMandatory and Recommended Forms in or Affecting Fiscal Functions .25-600Forms Supply .25-601Retention Schedule .25-602Forms .25-605CALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 138Effective 7/1/86

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FISCAL MANAGEMENT AND CONTROLFORMSHandbook25-600MANDATORY AND RECOMMENDED FORMS USED IN ORAFFECTING FISCAL FUNCTIONS25-600 (Cont.)25-600The following SDSS forms are mandatory, except for those marked * which are recommended only. Ifmandatory forms are not suitable to special mechanical equipment of a county, forms designed by the county,adapted to such mechanical use, may be used in lieu thereof upon prior written approval of SDSS. Such forms,to be approved, must accomplish the purposes and provide all of the data required on mandatory forms.Wherever possible in each of the following nine (9) categories of forms, parenthetical reference is made in thecategory title to that chapter in Division 25 of the Manual of Policies and Procedures which contains generalinformation relating to the area of activity of the forms in that category.FORM NUMBERI.AUTHORIZATION AND AUTHORIZATION CONTROL (see Chapter 25-200)ABCD 278LABCD 278M*ABCD 821*ABCD 822II.List of Authorizations to Start, Change or Stop Aid PaymentsAuthorizations to Start, Change or Stop Aid PaymentsBatch Voucher of Individual County AuthorizationsRegister of County AuthorizationsAID CLAIMS (see Chapter 25-700)A. Monthly ClaimsABCD 801ABCD 820AD 800AAid Payroll (Contra Roll)Reconciliation Statement, County Authorizations to Auditor's PaymentsSummary Report of Assistance Expenditures-Adoption AssistanceProgram/FederalAD 800BSummary Report of Assistance Expenditures-Adoption AssistanceProgram/Nonfederal (includes Aid for the Adoption of Children-AAC)CA 800Summary Report of Assistance Expenditures-Aid to Families withDependent ChildrenCA 800 FC (FED)Summary Report of Assistance Expenditures-Federal Children in FosterCare* CA 800 FC.1 (FED)Foster Care Facility Expenditure StatementAmounts not Reimbursable from Federal Funds* CA 800 FC.2 (FED)Foster Care Facility Expenditure StatementAmounts not Reimbursable from State FundsCA 800A FC (NONFED) Summary Report of Assistance Expenditures-Nonfederal Children inFoster CareDFA 843Federal Funds Claimable Based on the Expenditures for RefugeeResettlement, Cuban Program Phasedown and Cuban/Haitian EntrantRecipients in Receipt of Nonfederal AFDC-FCDFA 844 RDPAdditional Federal Funds Claimable Based on the Nonfederal Share ofExpenditures for Refugee Demonstration Project Recipients (RDP)DFA 847Additional Federal Funds Claimable Based on the Nonfederal Share ofExpenditures for Refugee Resettlement, Cuban Program Phasedown andCuban/Haitian Entrant Recipients in Receipt of Federal AFDC-FCDFA 859Federal Funds Claimable Based on Expenditures for Time EligibleRefugees and Entrants in Receipt of General AssistanceDFA 863Additional Federal Funds Claimable Based on the Nonfederal Share ofExpenditures for Refugee Resettlement and Cuban/Haitian EntrantRecipients in Receipt of Emergency Assistance-Unemployed ParentCALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 139Effective 7/1/86

FISCAL MANAGEMENT AND CONTROLFORMS25-600 (Cont.)25-600MANDATORY AND RECOMMENDED FORMS USED IN ORAFFECTING FISCAL FUNCTIONS (Continued)SC 800SOC 800Quarterly ClaimsAD 800AD 801ADFA 837EL 800III.25-600Summary Report of Special CircumstancesSummary Report of Assistance Expenditures EmergencyAssistance- Foster CareSummary Report of Assistance Expenditures EmergencyAssistance-Unemployed ParentSOC 801B.HandbookCertification - Adoption Cost of Care Subvention UnderW&IC 16106Adoption Cost of Care Claim (W&I Code Section 16106)Summary Report of Assistance Expenditures Old Age Security,Aid to the Blind, and Aid to the DisabledSummary Report of Uncollected Loans (For Claiming Againstthe Emergency Revolving Fund)C.(Deleted by Manual Letter No. FMC-86-04, effective 7/1/86.)D.(Deleted by Manual Letter No. FMC-86-04, effective 7/1/86.)CLAIMS FOR ADMINISTRATIVE EXPENDITURES (See Chapter 25-800)As the County Welfare Department Administrative Expense Claim is frequently modified due toprogram changes during the fiscal year, many of the individual form numbers and names are notidentified below. The forms listed below are not displayed in Section 25-605 since they are subject torevision each quarter. Updates and current form numbers for the Administrative Expense Claim will betransmitted to the counties on a current basis via All-County Letter.The Administrative Expense Claim is composed of the following form categories:DFA 43DFA 46DFA 47DFA 48DFA 48ADFA 50DFA 52DFA 53DFA 323DFA 325.1DFA 325.1ADFA 325.1AADFA 325.1BDFA 327.1-.11DFA 403DFA 419DFA 856Eligibility and Nonservice Time StudySocial Services Time StudySocial Services Time Study Summary and Program AllocationsElectronic Data Processing Time Study (all other)Electronic Data Processing Time Study (statewide systems)Staff Development Time StudyEmployment Services Time StudyEmployment Services Time Study Summary and Program AllocationsEligibility and Nonservices Time Study Summary and Program AllocationsExpenditures Schedule and CertificationElectronic Data Processing Schedule (all other)Electronic Data Processing Schedule (statewide systems)Direct Cost ScheduleExpenditures Distribution and Funding PagesReconciliation of Time Studies to Allocable Salary PoolsClaim Summary SheetWelfare Fraud Time StudyCALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 140Effective 7/1/86

FISCAL MANAGEMENT AND CONTROLFORMSHandbook25-600V.MANDATORY AND RECOMMENDED FORMS USED IN ORAFFECTING FISCAL FUNCTIONS (Continued)25-600CLAIMS FOR CHILD SUPPORT ADMINISTRATIVE EXPENDITURES (see Section 25-950)CS 355CS 356.1CS 356.2CS 356.3CS 356.4CS 356.5CS 356.6CS 356.7CS 356.8CS 357VI.25-600DA Employee's Child Support Time Study for IV-D FunctionsIV-D Child Support Expenditure Schedule and Certification (front)IV-D Child Support Expenditure Schedule and Certification (back)IV-D Child Support Time Summary and Activity Allocation RatiosIV-D Child Support Program Distribution, Total Allocable CostsIV-D Child Support Program Distribution, Direct CostsIV-D Child Support Program Distribution, Total Allocable and Direct CostsIV-D Child Support Program Distribution Report of Total ExpendituresIV-D Child Support Program - Personal ServicesGroup A Individual Employee Worksheet, Local IV-D Agency - Direct CostsCHILD SUPPORT SPACE COST CLAIM REQUEST FORMS (Obsolete. Deleted by Manual LetterNo. FMC-88-02, effective 9/1/88.)VII. CHILD SUPPORT INCENTIVE CLAIMS (see Chapter 25-900)CS 278LCS 278MCS 800CS 801CS 801ACS 801BCS 820CS 821CS 822CS 831Child and Spousal Support Case History and List of AuthorizationsChild and Spousal Support Transmittal/Action DocumentSummary Report of Child and Spousal Support PaymentsChild and Spousal Support Payroll Form for Collections and DisbursementSummary CS 800 Reconciliation - Intracounty/InterstateIntercounty Summary CS 800 ReconciliationChild/Spousal Support Collections Summary ReportSupport Collection ReportSummary CS 820 Reconciliation StatementCollection Agency - Accounts ReceivableVIII. OVERPAYMENT AND REPAYMENT RECEIVABLE RECORDS (see Chapter 25-400)* ABCD 830 Overpayment Receivable RecordABCD 831 Repayment Receivable RecordIX.MISCELLANEOUS FORMSGEN 215*SuggestedForm HGEN 127Claim for Reimbursement - Local Agency Special Project (see Chapter25-800)Substitute Payee CertificationNotice of Form ChangeCALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-88-02Page 141Effective 9/1/88

25-60125-601FISCAL MANAGEMENT AND CONTROLFORMSHandbookFORMS SUPPLY25-601Forms developed for operation of the welfare programs will be printed by SDSS and made available to thecounty welfare departments and other agencies requiring their use.SDSS will keep users informed of new and revised forms, where to order a supply, whether the form is free orsold, whether an initial supply is being sent and whether old issues of a revised form may be used.SDSS will make available semiannually the County Forms Catalogue, listing free and sold forms availablethrough the SDSS Warehouse.25-602RETENTION SCHEDULES25-602State forms listed in Chapter 25-600 and their supporting records must be retained by the county as required by23-353 unless notification has been received from SDSS that there are unresolved audit issues or that recordsmust be retained for other needs of the department. The exceptions are:1.ABCD 830 original shall be retained in the case record.2.All DFA 117 forms shall be retained for the minimum period after disposal of the property.This retention schedule is for fiscal purposes of SDSS and does not authorize the county to destroy any of theserecords which have a longer retention period required by other laws or regulations.CALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 142Effective 7/1/86

FISCAL MANAGEMENT AND CONTROLFORMSHandbook25-605I.FORMS25-605 (Cont.)25-605AUTHORIZATION AND AUTHORIZATION CONTROL (see Chapter 25-200)ABCD 278LCALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 143Effective 7/1/86

25-605 (Cont.)25-605I.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)Handbook25-605AUTHORIZATION AND AUTHORIZATION CONTROL (Continued)Reverse of ABCD 278LCALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 144Effective 7/1/86

Handbook25-605I.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)25-605 (Cont.)25-605AUTHORIZATION AND AUTHORIZATION CONTROL (Continued)ABCD 278M and ReverseCALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 145Effective 7/1/86

25-605 (Cont.)25-605I.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)Handbook25-605AUTHORIZATION AND AUTHORIZATION CONTROL (Continued)ABCD 821CALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 146Effective 7/1/86

FISCAL MANAGEMENT AND CONTROLFORMSHandbook25-605I.FORMS (Continued)25-605 (Cont.)25-605AUTHORIZATION AND AUTHORIZATION CONTROL (Continued)Reverse of ABCD 821CALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 147Effective 7/1/86

25-605 (Cont.)25-605I.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)Handbook25-605AUTHORIZATION AND AUTHORIZATION CONTROL (Continued)ABCD 822CALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 148Effective 7/1/86

Handbook25-605II.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)25-605 (Cont.)25-605AID CLAIMS (see Chapter 25-700)A.Monthly Claims -- ABCD 801CALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 149Effective 7/1/86

25-605 (Cont.)25-605II.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)Handbook25-605AID CLAIMS (Continued)A.Monthly Claims -- ABCD 820CALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 150Effective 7/1/86

Handbook25-605II.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)25-605 (Cont.)25-605AID CLAIMS (Continued)A.Monthly Claims -- AD 800ACALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 151Effective 7/1/86

25-605 (Cont.)25-605II.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)Handbook25-605AID CLAIMS (Continued)A.Monthly Claims -- Reverse of AD 800ACALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 152Effective 7/1/86

Handbook25-605II.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)25-605 (Cont.)25-605AID CLAIMS (Continued)A.Monthly Claims -- AD 800BCALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 153Effective 7/1/86

25-605 (Cont.)25-605II.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)Handbook25-605AID CLAIMS (Continued)A.Monthly Claims -- Reverse of AD 800BCALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 154Effective 7/1/86

Handbook25-605II.FISCAL MANAGEMENT AND CONTROLFORMSFORMS (Continued)25-605 (Cont.)26-605AID CLAIMS (Continued)A.Monthly Claims -- CA 800CALIFORNIA-DSS-MANUAL-FMCMANUAL LETTER NO. FMC-86-04Page 155Effective 7/1/86