6-RFP Cost Report.xlsx

XLSX spreadsheet 102 KB Posted Mar 26, 2026

Attached to: Evaluation Services SSCP-000023 JDRC
Solicitation number: Not on record
Issued by: Delaware County, Pennsylvania

About this file

Written by GovTribe AI · Mar 27, 2026

This file is a budget packet template and cost reporting form designed by Delaware County for human services contract submissions. The document provides standardized instructions and spreadsheet tabs for agencies requesting county contracts to report program expenditures, administrative costs, fixed asset purchases, and personnel rosters. The budget packet is structured to require data entry in a single location with automatic population to all relevant reporting sections. All dollar amounts must be entered as whole numbers without decimal points or formulas to ensure proper calculation functionality. The template includes tabs for Agency Coversheet information (agency name, fiscal year, contact details, and address), Program Expenditures (detailing costs for personnel services, operating expenses, and equipment), Administrative Costs (allocating indirect administrative expenses), Fixed Asset Purchases (documenting equipment and asset acquisitions with cost allocations), and Roster of Personnel (listing employee names, positions, salaries, and time allocations between direct and administrative program costs).

The budget packet establishes detailed expense categories for consistent reporting across agencies, including personnel benefits (medical, dental, prescription, vision, workers' compensation, retirement, life insurance, FICA, and tuition reimbursement), occupancy costs (rent, utilities, insurance, janitorial services), communications, supplies, treatment and supportive services, transportation, and miscellaneous operating expenses. The document includes a comprehensive CCRI Code Chart referencing provider types, specialty codes, procedure codes, price modifiers, information modifiers, units of service, and cost center assignments for healthcare and social service billing purposes. The template is designed to support Delaware County's evaluation and contracting processes for non-residential youth prevention, diversion, and intervention services, with cost reporting aligned to support performance-based contracting frameworks and program impact evaluation requirements.

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Other files

File	Type	Posted
1-Appendix F.pdf	PDF	Mar 26, 2026
5-Appendix FF.pdf	PDF	Mar 26, 2026
12-EvaluationSvcs RFP JDRC .pdf	PDF	Mar 26, 2026
2-Appendix AA FFS CoverSheet.pdf	PDF	Mar 26, 2026
8-Appendix AA.pdf	PDF	Mar 26, 2026
4-Appendix EE.pdf	PDF	Mar 26, 2026
9-Appendix CC.pdf	PDF	Mar 26, 2026
7-Appendix II.pdf	PDF	Mar 26, 2026
10-Appendix U.pdf	PDF	Mar 26, 2026
11-Appendix LL.pdf	PDF	Mar 26, 2026
3-Appendix DD.pdf	PDF	Mar 26, 2026

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Instructions

Delaware County Budget Packet Request Instructions

The budget packet is designed to require information to only be entered in one place and then carry to all other places where required. The cells which require data entry are highlighted in yellow.

Please note that all dollar amounts are to be entered as whole numbers, using decimal points or formulas will create errors with the calculations.

Agency Coversheet Tab:
	Agency	Enter the name of the agency

Fiscal Year Ending Select the last date of the fiscal year for which the contract is being requested from the drop down menu

Fiscal Contact Name Enter the name of the individual to contact with questions regarding the contract submission

Fiscal Contact Phone Enter the individual's phone number

Fiscal Contact Email Enter the individual's email

	Agency Address	Enter the address of the agency
Program Expenditures Tab
	Program Cost Center	List the cost center for the program if applicable
	Employee Benefits	Medical Insurance (medical, dental, prescription, vision, etc.), Workman's Compensation Insurance, Retirement, Life insurance, Tuition Reimbursement, FICA, and other benefits that are formally established and consistently applied through agency polices.
	Miscellaneous Personnel	Staff development, purchased personnel services, professional liability insurance, professional fees, auditing expenses, etc..
	Occupancy	Rent, mortgage payment, real estate taxes, property insurance, utilities, janitorial services, pest control, snow removal, landscaping, etc.
	Communication	Telephone, cell phone, postage, printing, advertisement, etc.
	Program Supplies	Administrative/Office supplies
	Treatment and Supportive Supplies	Medical supplies, clothing, household goods, recreational supplies, educational supplies, etc.
	Transportation	Maintenance/repair of vehicles, gas, mileage reimbursement, parking, registration, inspection, insurance, etc.
	Miscellaneous Operating Expenses	Interest expenses, membership fees, expenses not included in categories listed. Indicate the costs associated with the identified expenses.
	Repair and Improvement of Fixed Assets	Activities to restore, maintain, or extend and asset and its useful life
Administrative Costs Tab
	Employee Benefits	Medical Insurance (medical, dental, prescription, vision, etc.), Workman's Compensation Insurance, Retirement, Life insurance, Tuition Reimbursement, FICA, and other benefits that are formally established and consistently applied through agency polices.
	Miscellaneous Personnel	Staff development, purchased personnel services, professional liability insurance, professional fees, auditing expenses, etc..
	Occupancy	Rent, mortgage payment, real estate taxes, property insurance, utilities, janitorial services, pest control, snow removal, landscaping, etc.
	Communication	Telephone, cell phone, postage, printing, advertisement, etc.
	Administrative Supplies	Administrative/Office supplies
	Transportation	Maintenance/repair of vehicles, gas, mileage reimbursement, parking, registration, inspection, insurance, etc.
	Miscellaneous Operating Expenses	Interest expenses, membership fees, expenses not included in categories listed. Indicate the costs associated with the identified expenses.
	Repair and Improvement of Fixed Assets	Activities to restore, maintain, or extend and asset and its useful life
	Agency Indirect Administrative Expenses	Indirect costs allocated to the agency
Fixed Asset Purchases Tab
	Description of Item	List the item being requested
	Quantity	Indicate the quantity of the items
	Date of Acquisition	Anticipated date of acquisition
	Per Item Cost	Cost per item being requested
	Amount Eligible for DHS Participation	Amount of total cost that can be reimbursed with DHS funds
	Agency Program	Select the appropriate Agency Program to which the asset is being charged. If the costs are distributed between multiple programs, the asset must be listed for each program
	Amount Charged as Direct Cost	Amount of asset cost that can be directly charged to the agency program
	Amount Charged as Administrative Cost	Amount of asset cost that is an administrative cost to the agency program
	Cost Center	Indicate the cost center in which the asset is included if applicable
Roster of Personnel Tab

Employee Name	Enter the employee's name
County Definition Position Classification	The position title based on Civil Service Definitions
Grade Level	The position grade level
Total Annual Approved Salary	Employee's approved annual salary
Actual Annual Salary	Employee's approved annual salary
Total Hours Per Week at Agency	The total number of hours the employee works per week at the agency
Total Direct and Indirect Salary for County Program Identified	Employee's salary charged to the program
Amount Charged as Direct Cost	Employee's salary charged to the program as a direct cost
Amount Charged as Administrative Cost	Employee's salary charged to the program as an administrative cost
Total Direct and Indirect Hours Per Week for County Program Identified	Total number of hours the employee works per week which are being allocated to the program
Total Hours Per Week Charged as Direct Cost	Total number of hours per week the employee works which are being allocated to the program as a direct cost
Total Hours Per Week Charged as Administrative Cost	Total number of hours per week the employee works which are being allocated to the program as an administrative cost

Go to Agency Coversheet #'Agency%20Coversheet%20'!B6Go to Program Expenditures #'Program%20Expenditures'!A1Go to Program Administrative Costs #'Administration%20Costs'!A1Go to Program Fixed Asset Purchases #'Fixed%20Asset%20Purchases'!A1Go to Program Roster of Personnel #'Roster%20of%20Personnel'!A1 CCRI Code Charts

Pvr Type	Specialty Code	Proc Code	Price Mod	Info Mod	Units	Cost Center Assignment		Pvr Type	Specialty Code	Proc Code	Price Mod	Info Mod	Units	Cost Center Assignment
01	010	N/A			N/A	3.7	01010N/AN/A3.7	01	010	00104	AH	ET	1 hour	3.06
01	011	N/A			N/A	3.7	01011N/AN/A3.7	08	011	90791	HP	GT	1 treatment	3.08
01	013	N/A			N/A	3.7	01013N/AN/A3.7	08	013	90792	TF	H9	10 min	3.10
01	018	N/A			N/A	3.7	01018N/AN/A3.7	09	018	90832	TG	HA	110 min	3.11
01	022	N/A			N/A	3.7	01022N/AN/A3.7	11	022	90834	U7	HB	15 min	3.12
08	074	90792		HB	Occurrence	3.6	0807490792HBOccurrence3.6	17	074	90837	U9	HE	15 min	3.13
08	074	90846	UB	HB	15 min	3.6	0807490846UBHB15 min3.6	19	076	90846	UB	HK	20 min	3.14
08	074	90847	UB	HB	15 min	3.6	0807490847UBHB15 min3.6	21	080	90847		HO	25 min	3.15
08	074	90853	UB	HB	15 min	3.6	0807490853UBHB15 min3.6	21	081	90853		HT	30 min	3.16
08	074	90875		HB	Occurrence	3.6	0807490875HBOccurrence3.6	26	110	90870		HW	35 min	3.17
08	074	96101	TF	HB	per occurrence	3.6	0807496101TFHBper occurrence3.6	28	111	90875		HX	40 min	3.20
08	074	96101	TG	HB	per occurrence	3.6	0807496101TGHBper occurrence3.6	31	112	95816		SC	45 min	3.21
08	074	96101	UB	HB	per occurrence	3.6	0807496101UBHBper occurrence3.6	51	113	95819		TJ	5 min	3.22
08	074	96101		HB	per occurrence	3.6	0807496101HBper occurrence3.6	52	114	95822		U1	55 min	3.23
08	074	96118		HB	per occurrence	3.6	0807496118HBper occurrence3.6	53	115	95827		U2	60 min	3.24
08	074	90832		HB	30 min	3.6	0807490832HB30 min3.6	56	118	96101		UA	70 min	3.25
08	074	90834		HB	45 min	3.6	0807490834HB45 min3.6		119	96116		UC	80 min	3.26
08	074	90837		HB	60 min	3.6	0807490837HB60 min3.6		123	96118		UK	I hour	3.27
08	074	99201	UB	HB	15 min	3.6	0807499201UBHB15 min3.6		126	99201			N/A	3.28
08	074	99211	UB	HB	15 min	3.6	0807499211UBHB15 min3.6		175	99202			Occurrence	3.29
08	074	H0034		HB	15 min	3.6	08074H0034HB15 min3.6		190	99203			per diem	3.4
08	074	H0034		HK	15 min	3.6	08074H0034HK15 min3.6		215	99204			per diem or event	3.6
08	076	H0038		GT	15 min	3.27	08076H0038GT15 min3.27		221	99205			per diem or occurrence	3.7
08	076	H0038			15 min	3.27	08076H003815 min3.27		222	99211			per hour	12
08	080	T1015		HE	visit	3.6	08080T1015HEvisit3.6		267	99212			per occurrence	15
08	081	T1015		HE	visit	3.6	08081T1015HEvisit3.6		280	99213			Refer to the MA reference file	25
08	110	90846	UB		15 min	3.6	0811090846UB15 min3.6		315	99214			trip / encounter
08	110	90847	UB		15 min	3.6	0811090847UB15 min3.6		316	99215			visit
08	110	90853	UB		15 min	3.6	0811090853UB15 min3.6		322	99221
08	110	90870			1 treatment	3.6	08110908701 treatment3.6		339	99222
08	110	90875			Occurrence	3.6	0811090875Occurrence3.6		345	99223
08	110	95816			1 treatment	3.6	08110958161 treatment3.6		442	99231
08	110	95819			1 treatment	3.6	08110958191 treatment3.6		443	99232
08	110	95822			1 treatment	3.6	08110958221 treatment3.6		444	99233
08	110	95827			1 treatment	3.6	08110958271 treatment3.6		446	99238
08	110	96101	AH		per occurrence	3.25	0811096101AHper occurrence3.25		447	99241
08	110	96101	TF	HK	per occurrence	3.25	0811096101TFHKper occurrence3.25		448	99242
08	110	96101	TF		per occurrence	3.6	0811096101TFper occurrence3.6		450	99243
08	110	96101	TG	HK	per occurrence	3.25	0811096101TGHKper occurrence3.25		451	99244
08	110	96101	TG		per occurrence	3.6	0811096101TGper occurrence3.6		452	99245
08	110	96101	U7	HA	per hour	3.25	0811096101U7HAper hour3.25		456	99251
08	110	96101	U7	TJ	per hour	3.25	0811096101U7TJper hour3.25		512	99252
08	110	96101	U7		per hour	3.25	0811096101U7per hour3.25		513	99253
08	110	96101	UB		per occurrence	3.6	0811096101UBper occurrence3.6		515	99254
08	110	96101		HK	per occurrence	3.25	0811096101HKper occurrence3.25		520	99255
08	110	96101			per occurrence	3.6	0811096101per occurrence3.6		521	99281
08	110	96116			per hour	3.25	0811096116per hour3.25		531	99282
08	110	96118	UB		per hour	3.25	0811096118UBper hour3.25		548	99283
08	110	96118		HK	per occurrence	3.25	0811096118HKper occurrence3.25		549	99284
08	110	96118			per occurrence	3.6	0811096118per occurrence3.6		559	99285
08	110	99201	UB		15 min	3.6	0811099201UB15 min3.6		560	99291
08	110	99211	UB		15 min	3.6	0811099211UB15 min3.6		800	99292
08	110	00104				3.6	08110001043.6		801	99304
08	110	90791			30 min	3.25	081109079130 min3.25		802	99305
08	110	90792			Occurrence	3.6	0811090792Occurrence3.6		803	99306
08	110	90832			30 min	3.6	081109083230 min3.6		804	99307
08	110	90834			45 min	3.6	081109083445 min3.6		805	99308
08	110	90837			60 min	3.6	081109083760 min3.6		806	99309
08	110	H0034		HK	15 min	3.6	08110H0034HK15 min3.6		807	99310
08	110	H0034			15 min	3.6	08110H003415 min3.6		808	99341
08	110	H2010		HK	15 min	3.6	08110H2010HK15 min3.6		809	99342
08	110	H2013			per diem	3.6	08110H2013per diem3.6		810	99343
08	800	H2014	UB	HA	15 min	3.25	08800H2014UBHA15 min3.25			G0176
08	800	H2014	UB		15 min	3.25	08800H2014UB15 min3.25			H0004
08	800	H2021	UB		15 min	3.25	08800H2021UB15 min3.25			H0018
08	801	H2019	UB		15 min	3.25	08801H2019UB15 min3.25			H0019
08	802	H0032	HP		15 min	3.25	08802H0032HP15 min3.25			H0030
08	802	H0032		HO	15 min	3.25	08 802H0032HO15 min3.25			H0031
08	803	H2012	UB		per hour	3.25	08803H2012UBper hour3.25			H0032
08	804	H2014	UB	HA	15 min	3.25	08804H2014UBHA15 min3.25			H0034
08	804	H2014	UB		15 min	3.25	08804H2014UB15 min3.25			H0035
08	804	H2021	UB		15 min	3.25	08804H2021UB15 min3.25			H0036
08	805	H2019	UB		15 min	3.25	08805H2019UB15 min3.25			H0037
08	806	H0032	HP		15 min	3.25	08806H0032HP15 min3.25			H0038
08	806	H0032		HO	15 min	3.25	08 806H0032HO15 min3.25			H0039
08	807	H2012	UB		per hour	3.25	08807H2012UBper hour3.25			H0043
08	808	H2014	UB	HA	15 min	3.25	08808H2014UBHA15 min3.25			H0045
08	808	H2014	UB		15 min	3.25	08808H2014UB15 min3.25			H0046
08	808	H2021	UB		15 min	3.25	08808H2021UB15 min3.25			H2010
08	809	H2019	UB		15 min	3.25	08809H2019UB15 min3.25			H2011
08	810	H0032	HP		15 min	3.25	08810H0032HP15 min3.25			H2012
08	810	H0032		HO	15 min	3.25	08 810H0032HO15 min3.25			H2013
09	548	H2014	UB	HA	15 min	3.25	09548H2014UBHA15 min3.25			H2014
09	548	H2014	UB		15 min	3.25	09548H2014UB15 min3.25			H2015
09	548	H2021	UB		15 min	3.25	09548H2021UB15 min3.25			H2016
09	549	H2019	UB		15 min	3.25	09549H2019UB15 min3.25			H2017
09	559	H0032	HP		15 min	3.25	09559H0032HP15 min3.25			H2019
09	559	H0032		HO	15 min	3.25	09559H0032HO15 min3.25			H2021
11	076	H0038		GT	15 min	3.27	11076H0038GT15 min3.27			H2023
11	076	H0038			15 min	3.27	11076H003815 min3.27			H2030
11	110	H0018		HE	per diem	3.06	11110H0018HEper diem3.06			H2033
11	110	H0031			15 min	3.06	11110H003115 min3.06			N/A
11	110	H0037			per diem	3.06	11110H0037per diem3.06			Refer to the MA reference file
11	110	H0037			per diem	3.6	11110H0037per diem3.6			S5150
11	110	T2048		HE	per diem	3.16	11110T2048HEper diem3.16			S5151
11	111	H0039		HB	15 min	3.23	11111H0039HB15 min3.23			S9125
11	111	H0039		HE	15 min	3.23	11111H0039HE15 min3.23			S9484
11	111	H0039			15 min	3.23	11111H003915 min3.23			S9485
11	112	H0004		HE	15 min	3.06	11112H0004HE15 min3.06			T1015
11	112	H0004		HE	15 min	3.6	11112H0004HE15 min3.6			T1016
11	113	96101	AH		per occurrence	3.25	1111396101AHper occurrence3.25			T1017
11	113	96101	TF		per occurrence	3.25	1111396101TFper occurrence3.25			T2003
11	113	96101	TG		per occurrence	3.25	1111396101TGper occurrence3.25			T2048
11	113	96101	U7	HA	per hour	3.25	1111396101U7HAper hour3.25
11	113	96101	U7	TJ	per hour	3.25	1111396101U7TJper hour3.25
11	113	96101	U7		per hour	3.25	1111396101U7per hour3.25
11	113	96101			per occurrence	3.25	1111396101per occurrence3.25
11	113	96116			per hour	3.25	1111396116per hour3.25
11	113	96118	UB		per hour	3.25	1111396118UBper hour3.25
11	113	96118			per occurrence	3.25	1111396118per occurrence3.25
11	113	90791			30 min	3.25	111139079130 min3.25
11	113	H0035	U7	HB	1 hour	3.08	11113H0035U7HB1 hour3.08
11	113	H0035	U7	UA	1 hour	3.08	11113H0035U7UA1 hour3.08
11	113	H0035	UB	UA	1 hour	3.08	11113H0035UBUA1 hour3.08
11	113	H0035		U2	I hour	3.08	11113H0035U2I hour3.08
11	113	H0035		UA	I hour	3.08	11113H0035UAI hour3.08
11	113	H2010		HK	15 min	3.08	11113H2010HK15 min3.08
11	114	96101	AH		per occurrence	3.25	1111496101AHper occurrence3.25
11	114	96101	TF		per occurrence	3.25	1111496101TFper occurrence3.25
11	114	96101	TG		per occurrence	3.25	1111496101TGper occurrence3.25
11	114	96101	U7	HA	per hour	3.25	1111496101U7HAper hour3.25
11	114	96101	U7	TJ	per hour	3.25	1111496101U7TJper hour3.25
11	114	96101	U7		per hour	3.25	1111496101U7per hour3.25
11	114	96101			per occurrence	3.25	1111496101per occurrence3.25
11	114	96116			per hour	3.25	1111496116per hour3.25
11	114	96118	UB		per hour	3.25	1111496118UBper hour3.25
11	114	96118			per occurrence	3.25	1111496118per occurrence3.25
11	114	90791			30 min	3.25	111149079130 min3.25
11	114	H0035	U7	U2	1 hour	3.08	11114H0035U7U21 hour3.08
11	114	H0035	U7		1 hour	3.08	11114H0035U71 hour3.08
11	114	H0035	UB	HA	1 hour	3.08	11114H0035UBHA1 hour3.08
11	114	H2010		HK	15 min	3.08	11114H2010HK15 min3.08
11	115	96101	AH		per occurrence	3.25	1111596101AHper occurrence3.25
11	115	96101	TF		per occurrence	3.25	1111596101TFper occurrence3.25
11	115	96101	TG		per occurrence	3.25	1111596101TGper occurrence3.25
11	115	96101	U7	HA	per hour	3.25	1111596101U7HAper hour3.25
11	115	96101	U7	TJ	per hour	3.25	1111596101U7TJper hour3.25
11	115	96101	U7		per hour	3.25	1111596101U7per hour3.25
11	115	96101			per occurrence	3.25	1111596101per occurrence3.25
11	115	96116			per hour	3.25	1111596116per hour3.25
11	115	96118	UB		per hour	3.25	1111596118UBper hour3.25
11	115	96118			per occurrence	3.25	1111596118per occurrence3.25
11	115	90791			30 min	3.25	111159079130 min3.25
11	115	H0004	UB	HE	15 min	3.17	11115H0004UBHE15 min3.17
11	115	H0004	UB	HK	15 min	3.17	11115H0004UBHK15 min3.17
11	115	H0004	UB	HT	15 min	3.17	11115H0004UBHT15 min3.17
11	115	H0004	UB	UK	15 min	3.17	11115H0004UBUK15 min3.17
11	115	T1016	UB	HK	15 min	3.17	11115T1016UBHK15 min3.17
11	115	T1016	UB	HT	15 min	3.17	11115T1016UBHT15 min3.17
11	115	T1016	UB	UK	15 min	3.17	11115T1016UBUK15 min3.17
11	115	T1016	UB		15 min	3.17	11115T1016UB15 min3.17
11	118	H0030			15 min	3.10	11118H003015 min3.10
11	118	H2011	U7	HT	15 min	3.10	11118H2011U7HT15 min3.10
11	118	H2011	U9	HK	15 min	3.10	11118H2011U9HK15 min3.10
11	118	H2011	UB	HE	15 min	3.10	11118H2011UBHE15 min3.10
11	118	H2011			15 min	3.10	11118H201115 min3.10
11	118	S9484			per hour	3.10	11118S9484per hour3.10
11	118	S9485			per diem	3.10	11118S9485per diem3.10
11	119	H0031			15 min	3.6	11119H003115 min3.6
11	119	H0046		ET	15 min	3.21	11119H0046ET15 min3.21
11	119	H0046		HK	15 min	3.6	11119H0046HK15 min3.6
11	119	H0046		HW	15 min	3.06	11119H0046HW15 min3.06
11	119	H0046		HW	15 min	3.6	11119H0046HW15 min3.6
11	119	H2017		H9	15 min	3.29	11119H2017H915 min3.29
11	119	H2017		HE	15 min	3.29	11119H2017HE15 min3.29
11	119	H2017		HW	15 min	3.29	11119H2017HW15 min3.29
11	119	H2019		HA	15 min	3.26	11119H2019HA15 min3.26
11	119	H2019		HK	15 min	3.26	11119H2019HK15 min3.26
11	119	H2033			15 min	3.26	11119H203315 min3.26
11	123	H0036		HB	15 min	3.24	11123H0036HB15 min3.24
11	123	H0036		HK	15 min	3.24	11123H0036HK15 min3.24
11	123	H0036			15 min	3.24	11123H003615 min3.24
11	123	H2030			15 min	3.24	11123H203015 min3.24
11	126	H0043			per diem or occurrence	3.22	11126H0043per diem or occurrence3.22
11	126	H0046			15 min	3.14	11126H004615 min3.14
11	126	H2015		HE	15 min	3.22	11126H2015HE15 min3.22
11	126	H2015		HK	15 min	3.28	11126H2015HK15 min3.28
11	126	H2015		HW	15 min	3.22	11126H2015HW15 min3.22
11	126	H2015		HX	15 min	15	11126H2015HX15 min15
11	126	H2016		HW	per diem or event	3.15	11126H2016HWper diem or event3.15
11	126	H2016			per diem	3.22	11126H2016per diem3.22
11	442	H2014	UB	HA	15 min	3.25	11442H2014UBHA15 min3.25
11	442	H2014	UB		15 min	3.25	11442H2014UB15 min3.25
11	442	H2021	UB		15 min	3.25	11442H2021UB15 min3.25
11	443	H2019	UB		15 min	3.25	11443H2019UB15 min3.25
11	444	H0032	HP		15 min	3.25	11444H0032HP15 min3.25
11	444	H0032		HO	15 min	3.25	11444H0032HO15 min3.25
11	446	H2014	UB	HA	15 min	3.25	11446H2014UBHA15 min3.25
11	446	H2014	UB		15 min	3.25	11446H2014UB15 min3.25
11	446	H2021	UB		15 min	3.25	11446H2021UB15 min3.25
11	447	H2019	UB		15 min	3.25	11447H2019UB15 min3.25
11	448	H0032	HP		15 min	3.25	11448H0032HP15 min3.25
11	448	H0032		HO	15 min	3.25	11448H0032HO15 min3.25
11	450	H2014	UB	HA	15 min	3.25	11450H2014UBHA15 min3.25
11	450	H2014	UB		15 min	3.25	11450H2014UB15 min3.25
11	450	H2021	UB		15 min	3.25	11450H2021UB15 min3.25
11	451	H2019	UB		15 min	3.25	11451H2019UB15 min3.25
11	452	H0032	HP		15 min	3.25	11452H0032HP15 min3.25
11	452	H0032		HO	15 min	3.25	11452H0032HO15 min3.25
11	548	96101	U7	HA	per hour	3.25	1154896101U7HAper hour3.25
11	548	96101	U7	TJ	per hour	3.25	1154896101U7TJper hour3.25
11	548	96101	U7		per hour	3.25	1154896101U7per hour3.25
11	548	96116			per hour	3.25	1154896116per hour3.25
11	548	96118	UB		per hour	3.25	1154896118UBper hour3.25
11	548	90791			30 min	3.25	115489079130 min3.25
11	548	H2014	UB	HA	15 min	3.25	11548H2014UBHA15 min3.25
11	548	H2014	UB		15 min	3.25	11548H2014UB15 min3.25
11	548	H2021	UB		15 min	3.25	11548H2021UB15 min3.25
11	549	96101	U7	HA	per hour	3.25	1154996101U7HAper hour3.25
11	549	96101	U7	TJ	per hour	3.25	1154996101U7TJper hour3.25
11	549	96101	U7		per hour	3.25	1154996101U7per hour3.25
11	549	96116			per hour	3.25	1154996116per hour3.25
11	549	96118	UB		per hour	3.25	1154996118UBper hour3.25
11	549	90791			30 min	3.25	115499079130 min3.25
11	549	H2019	UB		15 min	3.25	11549H2019UB15 min3.25
11	559	96101	U7	HA	per hour	3.25	1155996101U7HAper hour3.25
11	559	96101	U7	TJ	per hour	3.25	1155996101U7TJper hour3.25
11	559	96101	U7		per hour	3.25	1155996101U7per hour3.25
11	559	96116			per hour	3.25	1155996116per hour3.25
11	559	96118	UB		per hour	3.25	1155996118UBper hour3.25
11	559	90791			30 min	3.25	115599079130 min3.25
11	559	H0032	HP		15 min	3.25	11559H0032HP15 min3.25
11	559	H0032		HO	15 min	3.25	11559H0032HO15 min3.25
17	175	G0176	UB		1 hour	3.25	17175G0176UB1 hour3.25
19	190	90791			30 min	25	191909079130 min25
19	190	90832			30 min	3.6	191909083230 min3.6
19	190	90834			45 min	3.6	191909083445 min3.6
19	190	90837			60 min	3.6	191909083760 min3.6
19	190	90846	UB		15 min	3.6	1919090846UB15 min3.6
19	190	90847	UB		15 min	3.6	1919090847UB15 min3.6
19	190	90853	UB		15 min	3.6	1919090853UB15 min3.6
19	190	90875			Occurrence	3.6	1919090875Occurrence3.6
19	190	96101	AH		per occurrence	3.6	1919096101AHper occurrence3.6
19	190	96101	TF		per occurrence	3.6	1919096101TFper occurrence3.6
19	190	96101	TG		per occurrence	3.6	1919096101TGper occurrence3.6
19	190	96101	U7	HA	per hour	25	1919096101U7HAper hour25
19	190	96101	U7	TJ	per hour	25	1919096101U7TJper hour25
19	190	96101			per occurrence	3.6	1919096101per occurrence3.6
19	190	96116			per hour	25	1919096116per hour25
19	190	96118	UB		per hour	3.25	1919096118UBper hour3.25
19	190	96118			per occurrence	3.6	1919096118per occurrence3.6
19	548	H2014	UB	HA	15 min	3.25	19548H2014UBHA15 min3.25
19	548	H2014	UB		15 min	3.25	19548H2014UB15 min3.25
19	548	H2021	UB		15 min	3.25	19548H2021UB15 min3.25
19	549	H2019	UB		15 min	3.25	19549H2019UB15 min3.25
19	559	H0032	HP		15 min	3.25	19559H0032HP15 min3.25
19	559	H0032		HO	15 min	3.25	19559H0032HO15 min3.25
21	076	H0038		GT	15 min	3.27	21 076H0038GT15 min3.27
21	076	H0038			15 min	3.27	21076H003815 min3.27
21	215	T1016		HX	15 min	3.20	21215T1016HX15 min3.20
21	221	T1017	TF	HE	15 min	3.4	21221T1017TFHE15 min3.4
21	221	T1017	TF	HK	15 min	3.4	21221T1017TFHK15 min3.4
21	221	T1017	TF		15 min	3.4	21221T1017TF15 min3.4
21	222	T1017	UB	HE	15 min	3.4	21222T1017UBHE15 min3.4
21	222	T1017	UB	HK	15 min	3.4	21222T1017UBHK15 min3.4
21	222	T1017	UB	UC	15 min	3.4	21222T1017UBUC15 min3.4
21	222	T1017	UB		15 min	3.4	21222T1017UB15 min3.4
21	222	T1017		HE	15 min	3.4	21222T1017HE15 min3.4
21	222	T1017		HK	15 min	3.4	21222T1017HK15 min3.4
21	222	T1017		HT	15 min	3.4	21222T1017HT15 min3.4
26	267	T2003		HX	trip / encounter	3.15	26267T2003HXtrip / encounter3.15
28	280	Refer to the MA reference file			Refer to the MA reference file	3.6	28280Refer to the MA reference file Refer to the MA reference file 3.6
31	315	99281			Visit	3.6	3131599281Visit3.6
31	315	99282			Visit	3.6	3131599282Visit3.6
31	315	99283			Visit	3.6	3131599283Visit3.6
31	315	99284			Visit	3.6	3131599284Visit3.6
31	315	99285			Visit	3.6	3131599285Visit3.6
31	316	99201			10 min	3.6	313169920110 min3.6
31	316	99202			20 min	3.6	313169920220 min3.6
31	316	99203			30 min	3.6	313169920330 min3.6
31	316	99204			45 min	3.6	313169920445 min3.6
31	316	99205			60 min	3.6	313169920560 min3.6
31	316	99211			5 min	3.6	31316992115 min3.6
31	316	99212			10 min	3.6	313169921210 min3.6
31	316	99213			15 min	3.6	313169921315 min3.6
31	316	99214			25 min	3.6	313169921425 min3.6
31	316	99215			40 min	3.6	313169921540 min3.6
31	316	99281			Visit	3.6	3131699281Visit3.6
31	316	99282			Visit	3.6	3131699282Visit3.6
31	316	99283			Visit	3.6	3131699283Visit3.6
31	316	99284			Visit	3.6	3131699284Visit3.6
31	316	99285			Visit	3.6	3131699285Visit3.6
31	322	99201			10 min	3.6	313229920110 min3.6
31	322	99202			20 min	3.6	313229920220 min3.6
31	322	99203			30 min	3.6	313229920330 min3.6
31	322	99204			45 min	3.6	313229920445 min3.6
31	322	99205			60 min	3.6	313229920560 min3.6
31	322	99211			5 min	3.6	31322992115 min3.6
31	322	99212			10 min	3.6	313229921210 min3.6
31	322	99213			15 min	3.6	313229921315 min3.6
31	322	99214			25 min	3.6	313229921425 min3.6
31	322	99215			40 min	3.6	313229921540 min3.6
31	322	99281			Visit	3.6	3132299281Visit3.6
31	322	99282			Visit	3.6	3132299282Visit3.6
31	322	99283			Visit	3.6	3132299283Visit3.6
31	322	99284			Visit	3.6	3132299284Visit3.6
31	322	99285			Visit	3.6	3132299285Visit3.6
31	339	90846	UB	U1	15 min	3.6	3133990846UBU115 min3.6
31	339	90847	UB	U1	15 min	3.6	3133990847UBU115 min3.6
31	339	90853	UB	U1	15 min	3.6	3133990853UBU115 min3.6
31	339	90870			1 treatment	3.6	31339908701 treatment3.6
31	339	90875			Occurrence	3.6	3133990875Occurrence3.6
31	339	96101	TF	U1	per occurrence	3.6	3133996101TFU1per occurrence3.6
31	339	96101	TG	U1	per occurrence	3.6	3133996101TGU1per occurrence3.6
31	339	96101	UB	U1	per occurrence	3.6	3133996101UBU1per occurrence3.6
31	339	96101		U1	per occurrence	3.6	3133996101U1per occurrence3.6
31	339	96118		U1	per occurrence	3.6	3133996118U1per occurrence3.6
31	339	99201			10 min	3.6	313399920110 min3.6
31	339	99202			20 min	3.6	313399920220 min3.6
31	339	99203		U1	30 min	3.6	3133999203U130 min3.6
31	339	99203			30 min	3.6	313399920330 min3.6
31	339	99204		U1	45 min	3.6	3133999204U145 min3.6
31	339	99204			45 min	3.6	313399920445 min3.6
31	339	99205		U1	60 min	3.6	3133999205U160 min3.6
31	339	99205			60 min	3.6	313399920560 min3.6
31	339	99211		U1	5 min	3.6	3133999211U15 min3.6
31	339	99211			5 min	3.6	31339992115 min3.6
31	339	99212		U1	10 min	3.6	3133999212U110 min3.6
31	339	99212			10 min	3.6	313399921210 min3.6
31	339	99213		U1	15 min	3.6	3133999213U115 min 3.6
31	339	99213			15 min	3.6	313399921315 min3.6
31	339	99214		U1	25 min	3.6	3133999214U125 min3.6
31	339	99214			25 min	3.6	313399921425 min3.6
31	339	99215		U1	40 min	3.6	3133999215U140 min3.6
31	339	99215			40 min	3.6	313399921540 min3.6
31	339	99221			30 min	3.7	313399922130 min3.7
31	339	99222			30 min	3.7	313399922230 min3.7
31	339	99223			70 min	3.7	313399922370 min 3.7
31	339	99231			15 min	3.7	313399923115 min3.7
31	339	99232			25 min	3.7	313399923225 min3.7
31	339	99233			35 min	3.7	313399923335 min3.7
31	339	99238			Visit	3.7	3133999238Visit3.7
31	339	99241		GT	15 min	3.7	3133999241GT15 min3.7
31	339	99241			15 min	3.7	313399924115 min3.7
31	339	99242		GT	30	3.6	3133999242GT303.6
31	339	99242			30 min	3.7	313399924230 min3.7
31	339	99243		GT	40 min	3.6	3133999243GT40 min3.6
31	339	99243			40 min	3.6	313399924340 min3.6
31	339	99244		GT	60 min	3.6	3133999244GT60 min3.6
31	339	99244			60 min	3.6	313399924460 min3.6
31	339	99245		GT	80 min	3.6	3133999245GT80 min3.6
31	339	99245			80 min	3.6	313399924580 min3.6
31	339	99251			20 min	3.7	313399925120 min3.7
31	339	99252			40 min	3.7	313399925240 min3.7
31	339	99253			55 min	3.7	313399925355 min3.7
31	339	99254			80 min	3.7	313399925480 min3.7
31	339	99255			110 min	3.7	3133999255110 min3.7
31	339	99281			Visit	3.6	3133999281Visit3.6
31	339	99282			Visit	3.6	3133999282Visit3.6
31	339	99283			Visit	3.6	3133999283Visit3.6
31	339	99284			Visit	3.6	3133999284Visit3.6
31	339	99285			Visit	3.6	3133999285Visit3.6
31	339	99291			1 Hour	3.6	31339992911 Hour3.6
31	339	99292			30 min	3.6	313399929230 min3.6
31	339	99304			Visit	3.7	3133999304Visit3.7
31	339	99305			Visit	3.7	3133999305Visit3.7
31	339	99306			Visit	3.7	3133999306Visit3.7
31	339	99307			Visit	3.7	3133999307Visit3.7
31	339	99308			Visit	3.7	3133999308Visit3.7
31	339	99309			Visit	3.7	3133999309Visit3.7
31	339	99310			Visit	3.7	3133999310Visit3.7
31	339	99341			20 min	3.6	313399934120 min3.6
31	339	99342			30 min	3.6	313399934230 min3.6
31	339	99343			45 min	3.6	313399934345 min3.6
31	339	00104		U1		3.6	3133900104U13.6
31	339	90832			30 min	3.6	313399083230 min3.6
31	339	90834			45 min	12	313399083445 min12
31	339	90837			60 min	12	313399083760 min12
31	339	99201	UB		15 min	3.25	3133999201UB15 min3.25
31	339	99211	UB		15 min	3.25	3133999211UB15 min3.25
31	339	H2010		HK	15 min	3.25	31339H2010HK15 min3.25
31	339	H2010		U1	15 min	3.25	31339H2010U115 min3.25
31	339	Refer to the MA reference file			Refer to the MA reference file	3.6	31339Refer to the MA reference file Refer to the MA reference file3.6
31	345	99201			10 min	3.6	313459920110 min3.6
31	345	99202			20 min	3.6	313459920220 min3.6
31	345	99203			30 min	3.6	313459920330 min3.6
31	345	99204			45 min	3.6	313459920445 min3.6
31	345	99205			60 min	3.6	313459920560 min3.6
31	345	99211			5 min	3.6	31345992115 min3.6
31	345	99212			10 min	3.6	313459921210 min3.6
31	345	99213			15 min	3.6	313459921315 min3.6
31	345	99214			25 min	3.6	313459921425 min3.6
31	345	99215			40 min	3.6	313459921540 min3.6
31	345	99281			Visit	3.6	3134599281Visit3.6
31	345	99282			Visit	3.6	3134599282Visit3.6
31	345	99283			Visit	3.6	3134599283Visit3.6
31	345	99284			Visit	3.6	3134599284Visit3.6
31	345	99285			Visit	3.6	3134599285Visit3.6
31	548	H2014	UB	HA	15 min	3.25	31548H2014UBHA15 min3.25
31	548	H2014	UB	U1	15 min	3.25	31548H2014UBU115 min3.25
31	548	H2021	UB	U1	15 min	3.25	31548H2021UBU115 min3.25
31	549	H2019	UB	U1	15 min	3.25	31549H2019UBU115 min3.25
31	559	H0032	HP	U1	15 min	3.25	31559H0032HPU115 min3.25
31	559	H0032		HO	15 min	3.25	31559H0032HO15 min3.25
31	559	H0032		U1	15 min	3.25	31559H0032U115 min3.25
51	512	S5150			15 min	3.15	51512S515015 min3.15
51	512	S5151			per diem	3.15	51512S5151per diem3.15
51	513	H0045			per diem	3.15	51513H0045per diem3.15
51	513	S9125			per diem	3.15	51513S9125per diem3.15
51	515	H2014		HK	15 min	3.11	51515H2014HK15 min3.11
52	456	H0018		HB	per diem	3.16	52456H0018HBper diem3.16
52	456	T2048		HE	per diem	3.16	52456T2048HEper diem3.16
52	456	T2048		HK	per diem	3.16	52456T2048HKper diem3.16
52	456	T2048		HW	per diem	3.16	52456T2048HWper diem3.16
52	456	T2048		HX	per diem	3.16	52456T2048HXper diem3.16
52	456	T2048			per diem	3.16	52456T2048per diem3.16
52	520	T2048		SC	per diem	3.16	52520T2048SCper diem3.16
52	521	T2048			per diem	3.16	52521T2048per diem3.16
53	531	H2023		HW	15 min	3.12	53531H2023HW15 min3.12
53	531	H2023		HX	15 min	3.12	53531H2023HX15 min3.12
53	531	H2023			15 min	3.13	53531H202315 min3.13
56	560	H0019		SC	per diem	3.16	56560H0019SCper diem3.16

Agency Coversheet

DELAWARE COUNTY HUMAN SERVICES

BUDGET INFORMATION FOR CONTRACT REQUEST

Agency:

Fiscal Year Ending:

Federal Identification Number:

DUNS Number:

Fiscal Contact Email:

Fiscal Contact Phone:

Fiscal Contact Email:

Agency Address:

Return to Instructions Tab #Instructions!A5 Program Expenditures

REPORT OF EXPENDITURES BY COUNTY PROGRAM OFFICE

AGENCY:

FISCAL YEAR ENDING:

	Expenses
Program Cost Center (If Applicable)
I. EXPENDITURE ITEMS
A. Personnel Services	-
1. Wages and Salaries	-
2. Employee Benefits
3. Miscellaneous Personnel
B. Operating Expenses	-
1. Occupancy
2. Communications
3. Program Supplies
4. Treatment & Supportive Supplies
5. Transportation
6. Purchased Treatment Services
7. Miscellaneous Operating Expenses (Identify below)	-
a.
b.
c.
d.
e.
f.
C. Equipment & Other Fixed Assets	-
1. Purchase of Fixed Assets	-
2. Repairs & Improvement of Fixed Assets
II. PROGRAM COSTS (Sum of A, B and C)	-
III. ADMINISTRATIVE COSTS	-
IV. PROGRAM & ADMINISTRATIVE COSTS (Sum of II and III)	-
V. RETAINED EARNINGS (Maximum 3% of IV)
VI. TOTAL COSTS (Sum of IV and V)	-
VII. REVENUE
ADJUSTMENT BY COUNTY
VIII. TOTAL COUNTY COSTS ELIGIBLE (VI LESS VII)	-

Return to Instructions Tab #Instructions!A20 Administration Costs

ADMINISTRATIVE COSTS PRORATION SPREAD BY COUNTY PROGRAM OFFICE

AGENCY:

FISCAL YEAR ENDING:

Program Cost Center (If Applicable)	0
I. EXPENDITURE ITEMS
A. Personnel Services	-
1. Wages and Salaries	-
2. Employee Benefits
3. Miscellaneous Personnel
B. Operating Expenses	-
1. Occupancy
2. Communications
3. Administrative Supplies
4. Transportation
5. Miscellaneous Operating Expenses (Identify below)	-
a.
b.
c.
d.
e.
f.
C. Equipment & Other Fixed Assets	-
1. Purchase of Fixed Assets	-
2. Repairs & Improvement of Fixed Assets
D. AGENCY INDIRECT ADMINISTRATIVE EXPENSES
E. TOTAL ADMINISTRATIVE EXPENSES (A&B&C&D)	-
F. ADMINISTRATIVE REVENUE
G. TOTAL ADMINISTRATION (E-F)	-

Return to Instructions Tab #Instructions!A33 Fixed Asset Purchases

SCHEDULE OF EQUIPMENT PURCHASES BY COUNTY PROGRAM OFFICE

AGENCY:

FISCAL YEAR ENDING:

DESCRIPTION OF ITEM	QUANTITY	DATE OF ACQUISITION	PER ITEM COST	TOTAL COST	AMOUNT ELIGIBLE FOR DHS PARTICIPATION	AMOUNT CHARGED AS DIRECT COST	AMOUNT CHARGED AS ADMINISTRATIVE COST	COST CENTER (IF APPLICABLE)
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
				$ - 0
TOTAL				$ - 0	$ - 0	$ - 0	$ - 0

Return to Instructions Tab #Instructions!A46 Roster of Personnel

ROSTER OF PERSONNEL BY COUNTY PROGRAM OFFICE

AGENCY:

FISCAL YEAR ENDING:

COUNTY PROGRAM OFFICE:

EMPLOYEE NAME

COUNTY DEFINITION POSITION CLASSIFICATION

GRADE LEVEL

TOTAL ANNUAL COUNTY APPROVED SALARY

ACTUAL ANNUAL SALARY

TOTAL HOURS PER WEEK AT AGENCY

TOTAL DIRECT & INDIRECT SALARY FOR AGENCY PROGRAM IDENTIFIED

AMOUNT CHARGED AS DIRECT COST

AMOUNT CHARGED AS ADMINISTRATIVE COST

TOTAL DIRECT & INDIRECT HOURS PER WEEK FOR AGENCY PROGRAM IDENTIFIED

TOTAL HOURS PER WEEK CHARGED AS DIRECT COST

TOTAL HOURS PER WEEK CHARGED AS ADMINISTRATIVE COST

COST CENTER (IF APPLICABLE)

TOTAL $ - 0 $ - 0 $ - 0 $ - 0

Return to Instructions Tab #Instructions!A57

File details come from the government source that posted it. Updated Mar 27, 2026.