Form CFS613-5 "Differential Response Final Cash Assistance Reconciliation" - Illinois

Form CFS613-5 or the "Form Cfs613-5 "differential Response Final Cash Assistance Reconciliation" - Illinois" is a form issued by the Illinois Department of Children and Family Services.

Download a PDF version of the Form CFS613-5 down below or find it on the Illinois Department of Children and Family Services Forms website.

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Download Form CFS613-5 "Differential Response Final Cash Assistance Reconciliation" - Illinois

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Department of Children and Family Services
CFS 613-5 (8/2010)
Page
of
Differential Response Final Cash Assistance Reconcilation
FOR DCFS USE ONLY
1. Provider No.
2. Contract No.
-
Provider Name
3.
FEIN No.
Appropriation No.
Program Name
4.
Reporting Period
FROM:
Address
TO:
Zip Code
5.
Date Submitted
Phone
6.
D.R. Project Director
line 7
Amount of funds advanced to the agency for the program
Amount of cash assistance provided to clients
line 8
line 9
Amount of cash assistance that was not used by the client
Amount of assistance provided that was not authorized by DCFS
line 10
Amount of authorized assistance provided to the client (subtract line 9 and 10 from line 8)
-
line 11
line 12
Administration fee (multiply line 11 by administration fee allowed by contract)
400.00
Amount authorized to bill, unless amount exceeds contract (add line 11 and 12)
400.00
line 13
line 14
Maximum amount contract allows agency to bill
line 15
Amount agency is authorized to bill (enter the smaller amount of line 13 or 14)
Amount agency already returned to the Department
line 16
line 17
Amount agency should return to DCFS (subtract line 15 and 16 from line 7)
$
-
18.
SELLER'S CERTIFICATION
CONTRACT LIAISON
DATE
For Agency Provider Use
CERTIFICATION OF RECEIVING AGENCY
It is herby certified that the information provided on this
I hereby certify that the amounts listed above are an accurate
form has been reviewed for mathematical accuracy.
summary for payments received and services provided for the fiscal
year.
Provider's Signature
Position
HEAD OF UNIT OR AUTHORIZED AGENCY
DATE
Department of Children and Family Services
CFS 613-5 (8/2010)
Page
of
Differential Response Final Cash Assistance Reconcilation
FOR DCFS USE ONLY
1. Provider No.
2. Contract No.
-
Provider Name
3.
FEIN No.
Appropriation No.
Program Name
4.
Reporting Period
FROM:
Address
TO:
Zip Code
5.
Date Submitted
Phone
6.
D.R. Project Director
line 7
Amount of funds advanced to the agency for the program
Amount of cash assistance provided to clients
line 8
line 9
Amount of cash assistance that was not used by the client
Amount of assistance provided that was not authorized by DCFS
line 10
Amount of authorized assistance provided to the client (subtract line 9 and 10 from line 8)
-
line 11
line 12
Administration fee (multiply line 11 by administration fee allowed by contract)
400.00
Amount authorized to bill, unless amount exceeds contract (add line 11 and 12)
400.00
line 13
line 14
Maximum amount contract allows agency to bill
line 15
Amount agency is authorized to bill (enter the smaller amount of line 13 or 14)
Amount agency already returned to the Department
line 16
line 17
Amount agency should return to DCFS (subtract line 15 and 16 from line 7)
$
-
18.
SELLER'S CERTIFICATION
CONTRACT LIAISON
DATE
For Agency Provider Use
CERTIFICATION OF RECEIVING AGENCY
It is herby certified that the information provided on this
I hereby certify that the amounts listed above are an accurate
form has been reviewed for mathematical accuracy.
summary for payments received and services provided for the fiscal
year.
Provider's Signature
Position
HEAD OF UNIT OR AUTHORIZED AGENCY
DATE
INSTRUCTIONS FOR COMPLETING CASH ASSISTANCE RECONCILIATION AND ADVANCE REQUEST
This Reconciliation form is authorized for use with providers for Cash Assistance services to Department when a cash advance was provided by the Department to serve the
clients.
This Reconciliation is not authorized for any other Cash Assistance or other services.
12.
1.
PROVIDER NO.
ADMINISTRATION FEE
Insert your 6-digit DCFS I.D. number, and your name and address as it
Multiply the amount of authorized assistance provided to the client by the
appears in your contract.
Telephone number of person preparing
amount the agency is allowed to bill for their administrative fee.
reconciliation may be inserted.
13.
AMOUNT AUTHOIZED TO BILL, UNLESS AMOUNT EXCEEDS CONTRACT ALLOCATION
Add the amount of authorized assistance provided to the client (line 11) with
2.
CONTRACT NO.
the administrative fee (line 12).
For contracted service, insert contract number stated in contract.
For non-contracted services, type "non-contracted" above the contract
number.
14.
MAXIMUM AMOUNT CONTRACT ALLOWS AGENCY TO BILL
Enter the maximum amount that the contract allows the agency to bill.
This
3.
FEIN NO.
may be the contract allocation but could be an amount defined by the contract
Use the number as it appears in your contract.
(for example, a maximum amount the agency can bill for each client served).
4.
SERVICE REPORTING PERIOD
The term of the contract (i.e. From 7/1/07 To: 6/30/07).
15.
AMOUNT THE AGENCY IS AUTHORIZED TO BILL
Enter the smaller amount of the amount the the agency is authorized to bill
(line 13) and the maximum amount the contract allows the agency to bill (line
14).
5.
DATE SUBMITTED
Self-explanatory.
16.
AMOUNT AGENCY ALREADY RETURNED TO THE DEPARTMENT
Enter the total amount of funds the agency has already returned to the
6.
DCFS DIFFERENTIAL RESPONSE (DR) PROJECT DIRECTOR
Department for the fiscal year being reconciled.
Insert the name of Differntial Response (DR) Project Director who
authorized this service.
17.
AMOUNT AGENCY SHOULD RETURN TO DCFS
7.
AMOUNT OF FUNDS ADVANCED TO THE AGENCY FOR THE PROGRAM
Enter the total amount of cash advances, including both funds provided to
Subtract the amount that the agency already returned to the
the agency for cash assistance checks and for administrative fees for the
Department (line 16) from the amount of funds advanced to the
year.
agency for the program.
If the amount is a negative balance,
meaning the Department owes the agency money for providing the
service the agency should submit a bill for the amount.
If
the amount is a positive number, the agency should write a
8.
AMOUNT OF CASH ASSISTANCE PROVIDED TO CLIENTS
check for the amount owed.
The check should be made out to
Enter the total amount of cash assistance checks provided to the client for
"DCFS" and include the agency's contract number on the check.
the entire fiscal year.
The check should be sent to the contract liaison who should
report that the cash advances have been reconciled with the
9.
AMOUNT OF CASH ASSISTANCE THAT WAS NOT USED BY THE CLIENT
Treasurer, State of Illinois
Enter the amount of any cash assistance checks that were not used and voided
c/o Illinois Department of Children and Family Services
and any funds that were returned from the provider.
406 E. Monoe, Station 412
Springfield IL 62701
10.
AMOUNT OF CASH ASSISTANCE THAT WAS NOT AUTHORIZED BY DCFS
Enter the amount of assistance that DCFS has determined was not authorized
by DCFS and therefore should not have been provided.
18.
SELLER'S CERTIFICATION
An authorized official of the Provider must sign this Reconciliation and
include her or his position.
11.
AMOUNT OF AUTHORIZED ASSISTANCE PROVIDED TO THE CLIENT
Subtract the amount of assistance that was not used (line 9) and the amount
of assistance that was not authorized (line 10) from the amount of
assistance proviced to the client (line 8).
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