##### **J. SAMPLE REPORTS**

##### 

This appendix includes the Monthly Collection report examples that are
forwarded to the States via CONNECT:Direct. The sample reports that are
included in this appendix are:

1.  The OCSE Federal Offset Net Check Amount Report,

2.  The Dear Colleague Monthly Collection Report, and

3.  The Statement of Service Fee Report.

> OCSE FEDERAL OFFSET NET CHECK AMOUNT REPORT FOR

NOV PROCESSING YEAR 1999 01/27/1999

[STATE]{.underline} [OFFSETS]{.underline} [COLLECTIONS]{.underline}
[ADJUSTMENTS]{.underline} [ADJUSTMENT AMT]{.underline} [SERVICE
FEE]{.underline} [NET CHECK AMT]{.underline}

  ------- --------- --------------- ------- -------------- ------------ --------------
  AK      55        47,284.07       9       9,066.48       409.75       37,807.84

  AL      233       190,813.94      34      39,602.80      1,793.20     149,417.94

  AR      136       135,059.14      23      21,326.53      1,019.40     112,713.21

  AZ      183       223,822.42      37      37,170.00      1,392.80     185,259.62

  CA      1,936     2,040,634.19    392     392,856.67     14,444.90    1,633,332.62

  CO      153       152,283.34      30      32,770.29      1,139.85     118,373.20

  CT      153       202,496.21      31      46,669.48      1,175.50     154,651.23

  DC      86        37,825.82       10      9,026.82       724.40       28,074.60

  DE      33        30,782.01       4       2,136.01       248.95       28,397.05

  FL      583       560,252.24      105     115,596.72     4,343.35     440,312.17

  GA      391       357,770.52      33      37,203.76      2,912.95     317,653.81

  HI      80        54,123.54       27      37,731.43      640.95       15,751.16

  IA      164       171,331.01      39      47,559.71      1,234.20     122,537.10

  ID      93        90,071.81       7       4,676.40       723.85       84,671.56

  IL      405       361,758.07      31      29,322.62      3,116.45     329,319.00

  IN      236       242,988.80      39      37,423.67      1,758.20     203,806.93

  KS      151       161,002.79      34      26,485.69      1,124.95     133,392.15

  KY      144       126,231.68      37      37,383.86      1,072.80     87,775.02

  LA      161       143,152.84      10      10,230.29      1,219.60     131,702.95

  MA      161       147,395.51      33      45,079.27      1,247.50     101,068.74

  MD      190       177,432.16      24      23,604.44      1,415.50     152,412.22

  ME      95        90,808.69       19      20,414.28      710.85       69,683.56

  MI      622       668,305.76      90      135,680.38     4,633.90     527,991.48

  MN      139       123,541.31      29      28,705.92      1,035.55     93,799.84

  MO      240       225,843.14      53      49,338.12      1,788.00     174,717.02

  MS      118       97,037.89       17      21,421.48      879.10       74,737.31

  MT      35        23,769.57       4       2,823.59       265.40       20,680.58

  NC      213       172,528.24      34      38,343.79      1,586.85     132,597.60

  ND      42        42,107.92       3       2,257.13       312.90       39,537.89

  NE      79        45,836.06       14      13,342.08      602.50       31,891.48

  NH      44        36,155.08       6       5,817.59       327.80       30,009.69

  NJ      302       310,836.82      49      60,730.79      2,249.90     247,856.13

  NM      43        47,172.32       15      9,059.78       321.90       37,790.64

  NV      64        99,424.31       10      5,465.57       476.80       93,481.94

  NY      533       534,548.24      93      101,599.96     3,970.85     428,977.43

  OH      568       662,264.40      102     117,847.14     4,231.60     540,185.66

  OK      148       154,958.35      21      25,994.31      1,102.60     127,861.44

  OR      261       236,726.21      29      31,437.67      1,953.75     203,334.79

  PA      433       435,019.36      77      84,968.86      3,225.85     346,824.65

  PR      28        11,869.94       1       974.00         228.75       10,667.19

  RI      22        11,862.61       4       6,233.35       168.55       5,460.71

  SC      82        58,134.71       9       7,132.30       610.90       50,391.51

  SD      37        23,468.85       6       9,004.43       283.40       14,181.02

  TN      255       239,825.09      32      32,289.03      1,981.90     205,554.16

  TX      1,078     1,152,908.52    146     123,505.51     8,031.10     1,021,371.91

  UT      70        68,089.42       13      17,868.52      521.50       49,699.40

  VA      190       161,876.94      39      30,898.23      1,415.50     129,563.21

  VI      7         8,356.94        2       4,214.03       52.15        4,090.76

  VT      20        13,450.99       6       5,729.50       149.00       7,572.49

  WA      324       327,642.38      51      51,158.69      2,413.80     274,069.89

  WI      246       220,778.58      53      54,777.72      1,832.70     164,168.16

  WV      72        60,897.80       18      19,171.45      536.40       41,189.95

  WY      41        42,659.10       10      10,885.65      314.75       31,458.70

  TOTAL   12,178    12,063,217.65   2,044   2,172,013.79   91,375.55    9,799,828.31
  ------- --------- --------------- ------- -------------- ------------ --------------

DEAR COLLEAGUE

THE OFFICE OF CHILD SUPPORT ENFORCEMENT IS PLEASED TO FORWARD TO YOU THE

LATEST FEDERAL TAX REFUND YEAR. THE IRS SERVICE FEE IS BEING DEDUCTED

FROM THE TOTAL COLLECTIONS. THIS MONTHS COLLECTION REPORT RESULTED IN

THE FOLLOWING:

STATE: XXXXXXX
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

MONTH: OCTOBER
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

  -------------- ------ ------------- ------------- ---------- ------------- ----------
                        TOTAL                       TANF                     NON-TANF

                                                                             

                                      TAX           ADM        TAX           ADM

                                                                             

  TOTAL OFFSETS:        84            50            4          28            2

                                                                             

  AMOUNT                \$91,090.84   \$58,286.01   \$531.12   \$31,637.63   \$600.08
  COLLECTED:                                                                 

                                                                             

  SERVICE FEE:          \$635.10      \$372.50      \$36.00    \$108.60      \$18.00

                                                                             

  TOTAL                 22            16            0          6             0
  ADJUSTMENTS:                                                               

                                                                             

  AMOUNT                \$14,815.75   \$12,107.21   \$.00      \$2,708.54    \$.00
  ADJUSTED:                                                                  

                                                                             

  NET CHECK             \$75,639.99   \$45,806.30   \$495.12   \$28,756.49   \$582.08
  AMOUNT:                                                                    

                                                                             

                                                                             

  PY 1999        22     \$14,815.75   \$12,107.21   \$0.00     \$2,708.54    \$0.00
  ADJUSTMENTS:                                                               

                                                                             

  PY 1998        0      \$0.00        \$0.00        \$0.00     \$0.00        \$0.00
  ADJUSTMENTS:                                                               

                                                                             

  PY 1997        0      \$0.00        \$0.00        \$0.00     \$0.00        \$0.00
  ADJUSTMENTS:                                                               

                                                                             

  PY 1996        0      \$0.00        \$0.00        \$0.00     \$0.00        \$0.00
  ADJUSTMENTS:                                                               

                                                                             

  PY 1995        0      \$0.00        \$0.00        \$0.00     \$0.00        \$0.00
  ADJUSTMENTS:                                                               

                                                                             
  -------------- ------ ------------- ------------- ---------- ------------- ----------

IF YOU HAVE ANY QUESTIONS, PLEASE CALL THE OCSE

SPECIAL COLLECTION UNIT AT (202) 401-9389.

SPECIAL COLLECTION UNIT

> DEPARTMENT OF HEALTH AND HUMAN SERVICES
>
> OFFICE OF CHILD SUPPORT ENFORCEMENT
>
> STATEMENT OF SERVICE FEE

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

\* NAME OF STATE \* PERIOD COVERED \*

\* XXXXXXXXXXXXXXXXX \* OCTOBER \*

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

\* ORGANIZATION-PROVIDING SERVICE \* KIND OF SERVICE \*

\* OFFICE OF CHILD SUPPORT ENFORCEMENT \* FEDERAL OFFSET \*

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

\* ORGANIZATION \*

> \* CHILD SUPPORT ENFORCEMENT \*
>
> \* DIV OF SOC SERVICES \*
>
> \* XXXXXXXXXXXXXXXXXXXXXX \*
>
> \* XXXXXXXXXXXXXXXXXXXXXX \*
>
> \* XXXXXXXXXXXXXXXXXXXXXX \*
>
> \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*
>
> \* DESCRIPTION OF SERVICE FEE \*
>
> \* SEE MONTHLY COLLECTION REPORT: OCTOBER \*
>
> \* \*
>
> \* 78 CASES TAX OFFSET \$7.45 EACH \$581.10 \*
>
> \* 6 CASES ADM OFFSET \$9.00 EACH \$54.00 \*

\* \-\-\-\-\-\-\-\-\-- \*

\* TOTAL DEDUCTED FROM COLLECTIONS \$635.10 \*

\* \*

\* \*

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

\* PLEASE NOTE: IF YOU HAVE ANY QUESTIONS REGARDING THIS SERVICE FEE, \*

\* REFER TO: OFFICE OF CHILD SUPPORT ENFORCEMENT \*

\* 370 LENFANT PROMENADE, S.W. \*

\* WASHINGTON, D.C. 20447 \*

\* ATTN: SPECIAL COLLECTIONS UNIT \*

\* (202) 401-9389 \*

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

\* STATEMENT PREPARED : 10/22/1999 \*

\* \*

\* PLEASE KEEP A COPY OF THIS STATEMENT FOR YOUR RECORDS \*

\* \*

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*