3-Budget template HDA311 for DA.xlsx

XLSX spreadsheet 33 KB Posted Sep 26, 2025

Attached to: Health and Hygiene Vending Machine
Solicitation number: 25-51
Issued by: Montgomery County, Pennsylvania

About this file

Written by GovTribe AI · Sep 26, 2025

This document is a fiscal reporting template (HDA311) from the Pennsylvania Department of Health's Bureau of Drug and Alcohol Programs, specifically designed for Montgomery County's Drug & Alcohol Program. The template is a comprehensive year-to-date fiscal report and cash request form for tracking facility expenses, revenues, and reimbursement requests. The form includes detailed sections for tracking personnel services, operating expenses, and fixed assets, with columns for budgeted funds, previously expended funds, current period expenses, and remaining balances.

The fiscal document reveals that no actual funds have been entered into the template at the time of preparation (all fields show $0), suggesting it is a blank reporting form. The form includes provisions for tracking various revenue sources such as provider revenue, charitable income, client fees, insurance, and other third-party funds. It also provides a mechanism for certification by the facility's executive officer, ensuring accuracy and compliance with fiscal guidelines and contract provisions. Accompanying the main form is an additional HDA313 Personnel Roster template for detailing employee expenses across different funding categories, including Alcohol Tobacco and Other Drug (ATOD) funding sources.

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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
				$0
				$0
				$0
				$0
				$0
				$0
				$0
				$0
				$0
				$0
				$0
				$0
				$0
Total:				$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
Remarks

File details come from the government source that posted it. Updated Sep 26, 2025.