3-7 -Blank HDA311 for DA (1).xlsx
XLSX spreadsheet 35 KB Posted
- Solicitation number
- 26-19
- Issued by
- Montgomery County, Pennsylvania
About this file
This is a Year-to-Date Fiscal Report and Cash Request form (HDA 311) submitted to the Pennsylvania Department of Health, Bureau of Drug and Alcohol Programs, by the Montgomery County Drug & Alcohol Program (Single County Authority) as of January 3, 2023. The form documents cumulative financial activity for a contracted provider facility and includes sections for non-SCA revenue and income, year-to-date invoicing, facility expenses across multiple budget categories, and personnel roster information. The report encompasses eligible and non-eligible expenses, including personnel services, operating expenses, and fixed assets. All financial entries on this particular form show zero balances, indicating either a blank template or a reporting period with no recorded transactions.
The form serves as a standardized accounting and reimbursement mechanism within Pennsylvania's drug and alcohol services contracting structure. It requires certification by the facility's Executive Officer that all expenses and income have been reconciled with organizational records and comply with fiscal guidelines and contract provisions. The document includes provisions for tracking advance funding from the Single County Authority, cumulative revenue applicable to eligible expenses, and net cash requests for reimbursement. The Personnel Roster section (HDA 313) captures employee information, salary data, and funding source allocations across various program categories including ATOD (Alcohol, Tobacco, and Other Drug) funding, MH/MR funds, and additional funding sources. This standardized reporting framework ensures accountability and compliance in the administration of drug and alcohol prevention and treatment services at the county level.
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| 4-SAMPLE CONTRACT 2025-2026 MH Boilerplate.docx | DOCX document | |
| 5-SAMPLE 2026 Provider agreement FFS - 1.23.26 (1).docx | DOCX document | |
| 7-Appendix A document.docx | DOCX document | |
| 2-SAMPLE 2026 Provider agreement Cost Reimbursement-Treatment.docx | DOCX document | |
| 1-6 -Attachment H - Blank RFP Budget for MH (1).xlsx | XLSX spreadsheet | |
| 8-Instructions to Bidders Template.docx | DOCX document | |
| 6-Exhibit E-HHS Standard Terms Condition for Services rev 6-3-24.pdf | ||
| 9-RFP 26-19 Youth Prevention Education Student Assistance Program and Youth Intervention Services .docx | DOCX document | |
| 10-8 -2026 Prevention SAP Intervention Supplemental Documents R2.docx | DOCX document |
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Text version
HDA311-1
| HDA 311 (Revised 1/08) | YEAR-TO-DATE FISCAL REPORT AND CASH REQUEST FOR FACILITIES | Pennsylvania Department of Health | ||||
| Page One | Vendor# | Bureau of Drug and Alcohol Programs | ||||
| Date: | 01/03/23 | TO: | Montgomery | County Drug & Alcohol Program (SCA) |
| Facility | ||||
| ID #: | Name: | Report No.: | ||
| Address: | ||||
| City/State: | ZIP: | For Period of: | To: |
Program Activity Code Contract Number Total Funds Approved
| Section I - Cumulative NON-SCA Revenue & Income | Section I - Cumulative NON-SCA Revenue & Income | |||||||
| Part A- Cumulative Revenue & Income Receipts Applicable to Eligible Expenses | Part B - Cumulative Revenue & Income Applicable to Non-Eligible Expenses | |||||||
| Sources | Sources | |||||||
| 501 | Provider Revenue | * | $ - 0 | 501 | Revenue* | |||
| 502 | Provider Charitable Income | * | $ - 0 | |||||
| 503 | Provider Interest Income | $ - 0 | ||||||
| 504 | Client Fees | $ - 0 | 502 | Charitable Income * | ||||
| 505 | Private Health Insurance | $ - 0 | ||||||
| 506 | Medical Assistance | $ - 0 | *Identify | |||||
| 507 | Other Third Party Fees | $ - 0 | Total - Section I, Part B | $ - 0 | ||||
| 508 | Miscellaneous | $ - 0 | ||||||
| * Identify | Total - Section I Part A: | $ - 0 | Certification Statement |
| Section II - Year-to-Date Invoicing | I certify that I am the Executive Officer of said organization, and this | |||
| statement of income and expense for the period shown is true and | ||||
| 1. | Cumulative Eligible Expenses | correct to the best of my knowledge and belief; that the expenses | ||
| (Section III, Part A, Column 4) | $ - 0 | and income shown on these forms have been reconciled with the | ||
| related balances of the books of this organization; that the expenses | ||||
| 2. | Less: Cumulative Revenue & Income appl. to | are in accordance with fiscal guidelines, directives and provisions | ||
| eligible expenses (Section I, Part A, Total) | (-) | $ - 0 | of the contract/agreement, as required by the Single County | |
| Authority; and that the organization understands that any and all | ||||
| 3. | Cumulative Amount Eligible for Reimbursement | (=) | $ - 0 | all payments made hereunder are made in reliance by the Single |
| County Authority upon the statements herein made. | ||||
| 4. | Less: Cumulative Amount previously billed to SCA | (-) | $ - 0 |
| 5. | Cumulative Cash Request to SCA (3. less 4.) | (=) | $ - 0 | ||
| Prepared By: | Telephone: | ||||
| 6. | Funds Advanced to Facility by SCA | $ - 0 |
| 7. | Amount of advance funding applied to this invoice | (-) | $ - 0 | Facility Director/Administrator | Date |
| (Signature) | |||||
| 8. | Cumulative Amount of advance funding | ||||
| applied to eligible expenses | $ - 0 | SCA Approval | Date | ||
| (Signature) |
9. NET CASH REQUEST (5. LESS 7.) (=) $ - 0
HDA311-2
| HDA 311 (Revised 1/08) | 1 | 2 | 3 | 4 | 5 |
| Section III - Facility Expenses | Project Budget | Project Funds Expended | Cumulative Project | Balances of Project | |
| Part A- Eligible Expenses | Total Funds Approved | Expenses Previously | Expended for this | Funds Expended | Funds Available |
| Budget Categories | (All Sources) | Reported | Period | (Cols. 2 + 3) | (Cols. 1 - 4) |
| Personnel Services (100) | |||||
| 111 - Administrative Salaries | $ - 0 | $ - 0 | |||
| 112 - Administrative Benefits | - 0 | - 0 | |||
| 121 - Client-Oriented Services Salaries | - 0 | - 0 | |||
| 122 - Client-Oriented Services Benefits | - 0 | - 0 | |||
| 131 - Staff Development | - 0 | - 0 | |||
| Sub-total: Personnel Services | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Operating Expenses (300) | |||||
| 301 - Meeting and Conference Expenses | $ - 0 | $ - 0 | |||
| 302 - Consultant Expenses | - 0 | - 0 | |||
| 303 - Miscellaneous Personnel Expenses | - 0 | - 0 | |||
| 304 - Occupancy Expenses | - 0 | - 0 | |||
| 305 - Insurance | - 0 | - 0 | |||
| 306 - Communications | - 0 | - 0 | |||
| 307 - Office Supplies | - 0 | - 0 | |||
| 308 - Minor Equipment and Furniture | - 0 | - 0 | |||
| 309 - Medical Supplies and Drugs | - 0 | - 0 | |||
| 310 - Food and Clothing | - 0 | - 0 | |||
| 311 - Program Supplies | - 0 | - 0 | |||
| 312 - Staff Travel | - 0 | - 0 | |||
| 313 - Client Transport | - 0 | - 0 | |||
| 314 - Purchased Client-Oriented Services | - 0 | - 0 | |||
| 315 - Equipment Maintenance Expense | - 0 | - 0 | |||
| 316 - Equipment Leases | - 0 | - 0 | |||
| 317 - Motor Vehicle Maintenance Expense | - 0 | - 0 | |||
| 318 - Motor Vehicle Leases | - 0 | - 0 | |||
| 319 - Other Operating Expenses | - 0 | - 0 | |||
| 320 - Indirect Costs | - 0 | - 0 | |||
| Sub-total: Operating Expenses | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Fixed Assets (400) | |||||
| 401 - Equipment and Furniture | $ - 0 | $ - 0 | |||
| 402 - Motor Vehicles | - 0 | - 0 | |||
| 403 - Capital Improvements | - 0 | - 0 | |||
| 404 - Capital Purchases | - 0 | - 0 | |||
| Sub-total: Fixed Assets | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Total (Part A - Eligible Expenses) | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Part B - Non-eligible Expenses | |||||
| $ - 0 | $ - 0 | ||||
| $ - 0 | $ - 0 | ||||
| Total (Part B - Non-eligible Expenses) | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Grand Total of Project Expenses (Parts A&B) | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Expense Allocation: For the Grand Total Cumulative expenses (Column 4) indicate: _______% used for drug related services. _____% used for alcohol related services |
HDA313
| HDA313 (Rev 1/08) | PERSONNEL ROSTER | Commonwealth of Pennsylvania | |
| Department of Health | |||
| Provider Name: | Bureau of Drug and Alcohol Programs | ||
| SAP Number: | Reporting Period: |
Facility ID#(s): Prepared By:
| (From Facility /Services Directory) | (Name & Telephone Number) | ||||||||||||
| Employee Name | Position Classification and Position Number | HR/WK | Annual Salary | Total Expenses | Alcohol Tobacco and Other Drug Funding Expended ATOD - SCA | MH/MR Funds | Additional Funding Sources | ||||||
| Bureau of Drug and Alcohol Program Funds | Tobacco Prevention and Control Funds | Other ATOD Funds | |||||||||||
| Administration | Prevention | Treatment | Case Management | Administration | Direct Services | Administration Direct Services | Administration Direct Services | Administration Direct Services | |||||
| $0 | |||||||||||||
| $0 | |||||||||||||
| $0 | |||||||||||||
| $0 | |||||||||||||
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| Total: | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||
| Remarks |
File details come from the government source that posted it. Updated .