Attachment_III_-_Budget_Forms_(ACTUAL_COSTS)_.xlsx

XLSX spreadsheet 231 KB Posted Sep 19, 2023

Attached to: Behavioral Health Training Services
Solicitation number: 042-1615073-RM
Issued by: Orange County, San Francisco City, California

About this file

Written by GovTribe AI · May 12, 2025

This document is a comprehensive budget proposal template for the Orange County Health Care Agency's Behavioral Health Training Services contract for fiscal year 2023-2024. The document is designed for a contractor to complete a detailed budget proposal, with sections covering administrative costs, program costs, staffing, services and supplies, revenue details, and start-up costs. The proposal is due on October 19, 2023, for a contract period from July 1, 2024, to June 30, 2025, focusing on providing behavioral health focused trainings to the community, including parents/caregivers, school personnel, professionals, and other community members.

The budget template includes multiple worksheets for financial analysis, with placeholders for precise cost breakdowns across various categories such as salaries, benefits, services and supplies, subcontractors, and flexible funds. The document emphasizes detailed documentation of staff positions, full-time equivalents (FTEs), monthly salaries, benefits, and direct service hours. While the current template is populated with placeholder zeros, it is structured to allow a contractor to input specific financial and staffing information. The proposal requires hard-coded inputs and does not allow formula or link-based entries, ensuring accurate and transparent budget reporting. The maximum administrative costs are capped, and the document provides guidance on variance explanations and cost allocations.

View the file

Other files

File	Type	Posted
RFP_Behavioral_Health_Training_Services_U.pdf	PDF	Sep 19, 2023
Campaign_Contribution_Disclosure_Form_Update.pdf	PDF	Sep 5, 2023
Attachment_II_-_Forms_A-E_.xlsx	XLSX spreadsheet	Sep 5, 2023
Attachment_I_-_Sample_Contract.pdf	PDF	Sep 5, 2023

On GovTribe

Work with this file

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

Procurement Budget Guide

Proposal and Budget Guide
	Indirect/Administrative Costs Narrative	Are those costs: (a) incurred for a common or joint purpose of benefiting more than one cost objective (i.e. more than one program or contract), and (b) not directly attributable to the cost of providing direct services (i.e. supportive services such as administrative management, fiscal, human resources, etc.). The Indirect/Administrative Costs cannot exceed a maximum percentage (%) of the program costs or as directed in the RFP and/or by Funding Source for the total program costs.
	Cost Allocation Plan	Narrative that details all costs, including a key for cost centers to distinguish costs that are to be allocated under the proposal..
	Salaries & Benefits Narrative/Details (Including Leave Accrual)	Explain in detail who in your organization is paid under this contract and provide detailed information and percentages for employee benefits and taxes. Leave Accrual: Explain the vacation/other leave accrual and charging process that your organization uses.
	Budget Narrative/Details	Include Staffing and Services & Supplies (S&S) narrative. Staffing: Narrative must describe each position in the contract (Administrative & Program) and their function(s). S&S: Give specific details on each budget line requested (Administrative & Program). Any variances from your current agreement needs to be explained for both the staffing and S&S.

Program Description Documents
	Program Organization Chart	Chart should be Program specific and include Title, Staff Name (if known), FTE.
	Job Descriptions	Job Descriptions need to be specific to the program being proposed and their function in the program. If you propose subcontracts include information on their job function; including term, hourly rate, total cost, and scope of work. Remember: Job Descriptions need to match the titles and details provided in the Staffing S&EB section.
	Program Narrative/Goals	Provide a brief description of your program (including philosophy and rationale). The what and why of your program. What are your objectives and goals. Provide information on structured activities. How you evaluate your program's success and improve any barriers/failures.
	Staffing Patterns	Staffing should include items such as FTEs and productivity levels for each position.
	Direct Service Hours (DSH), Units of Services, Outcomes	If applicable; detail your proposed DSH, Units of Services, number of clients served, Outcome data, referrals/linkages, etc.

Proposal Reminders
Narratives	Narratives need to be clearly written and well thought out; they should explain and mirror your strategic program plan and goals.
Inputting Information	All inputs must be hard coded. Do not use any links or formulas to input any information into the budget package.
Questions/Clarifications	If you have any questions or need clarification regarding completing your budget package and documents, please contact the Procurement Administrator for clarification.
Final Review and Completion	Have your team conduct a final review/edit of the Proposed Budget package prior to submission.

&"Times,Bold"&8&F &A &"Times,Bold"&8&P of &N &"Times,Bold"&8Prepared By: Contract Administrator Draft: Date

P1 Budget

BUDGET AND MAXIMUM OBLIGATION WORKSHEET

Program Name

Location

FY 2023-2024

	VARIANCE
PROPOSED

Uyeda, Brian: Contract Administrator:

Amounts must match the original proposal. REVISED Uyeda, Brian: Contract Administrator:

Change to read "Approved" following negotiations and finalizing the budget and staffing. REVISED Uyeda, Brian: Contract Administrator:

Change to read "Approved" following negotiations and finalizing the budget and staffing.	Percentage
		BUDGET	BUDGET	VS.	Increase/
		FY 2023-2024	FY 2023-2024	PROPOSED	Decrease
	ADMINISTRATIVE COSTS
	Salaries	$0	$0	$0	0.0%
	Benefits	$0	$0	$0	0.0%
	Services & Supplies	$0	$0	$0	0.0%
	Professional Services	$0	$0	$0	0.0%
	Indirect Costs	$0	$0	$0	0.0%
	SUBTOTAL ADMIN COSTS	$0	$0	$0	0.0%
	Percent Administrative Cost to Program Cost	0.0%	0.0%	0.0%

PROGRAM COSTS
Salaries	$0	$0	$0	0.0%
Benefits	$0	$0	$0	0.0%
Services & Supplies	$0	$0	$0	0.0%
Subcontractors	$0	$0	$0	0.0%
Flexible Funds	$0	$0	$0	0.0%
SUBTOTAL PROGRAM COSTS	$0	$0	$0	0.0%
Start-Up Costs	$0	$0	$0	0.0%
TOTAL GROSS COSTS	$0	$0	$0	0.0%

REVENUES

Uyeda, Brian: Contract Administrator: All Requested Revenue funding amounts are obtained from the Approved NOE and subject to modification pending negotiations.

Uyeda, Brian: Contract Administrator:

Amounts must match the original proposal.

Uyeda, Brian: Contract Administrator:

Change to read "Approved" following negotiations and finalizing the budget and staffing.

Uyeda, Brian: Contract Administrator:

Change to read "Approved" following negotiations and finalizing the budget and staffing.			ERROR:#REF!	ERROR:#REF!
	Federal Medi-Cal (FFP)	$0		$0	0.0%	FFP %	0.00%	0.00%
	Medi-Cal Match	$0		$0	0.0%	State %	0.00%	0.00%
	SubTotal Medi-Cal	$0	$0	$0	0.0%
	% Medi-Cal Offset	0.0%	0.0%

Other Revenue (Patient Fees/Insurance)			$0	0.0%
Other Revenue (MHSA)			$0	0.0%
Other Revenue (County Discretionary)			$0	0.0%
Other Revenue_______________			$0	0.0%
Other Revenue_______________			$0	0.0%
SubTotal Other Revenue	$0	$0	$0	0.0%

Total Revenue	$0	$0	$0	0.0%
	0.0%	0.0%
State Funds	$0	$0	$0	0.0%
(Total Cost - Total Revenue)	0.0%	0.0%

Maximum Obligation	$0	$0	$0	0.0%
(Total Revenue + State Funds)	0.0%	0.0%

	PROPOSED	REVISED	VARIANCE
	BUDGET	BUDGET	REVISED
Cost/Minute Calculation	FY 2023-2024	FY 2023-2024	VS. PROPOSED
Total Contract DSH	0	0	0
Total Gross Cost	$0	$0	$0
Total Minutes	0	0	0
Cost/Min	$0.00	$0.00	$0.00

DSH Workload Standards
MH Services	0	0	0
Medication Services	0	0	0
TOTAL	0	0	0

Caseload Standard 0.00 0.00 0.00

&"Times,Bold"&8&F &"Times,Bold"&8&P of &N &"Times,Bold"&8Prepared By: Contract Administrator

P1 Staffing

STAFFING WORKSHEET

Program Name

Location

FY 2023-2024

VARIANCE PROPOSED

Uyeda, Brian: Contract Administrator:

Amounts must match the

original proposal.	REVISED	VARIANCE
			PROPOSED

Uyeda, Brian: Contract Administrator:

Amounts must match the original proposal. REVISED REVISED MONTHLY MONTHLY REVISED PROPOSED Uyeda, Brian: Contract Administrator:

Amounts must match the

original proposal.	REVISED		VARIANCE			VARIANCE
		FTE	FTE	vs. PROPOSED	SALARY	SALARY	vs. PROPOSED	VARIANCE EXPLANATION

Uyeda, Brian: All variances must be explained and included in this column. Please do not reference line-item variance explanations as being addressed in your narratives.

Variance explanations should be clear and concise. Some examples are as follows:

FTE

"Increased staffing required to serve an additional _____ clients/slots."

"New proposed position due to _____."

S&EB

"Proposed merit increase of ___%."

"New position due to _____."

S&S "Historic usage shows increase/decrease of funds required."

"Allocation cost for this line increased/decreased due to proposed increase/decrease in FTE."

DSH & Caseload "Reduced DSH and caseload due to ______."

"New proposed DSH producing position due to_____."

Uyeda, Brian: Contract Administrator:

Amounts must match the original proposal.

Uyeda, Brian: Contract Administrator:

Amounts must match the

original proposal.				BENEFITS	BENEFITS	PROPOSED	REVISED	REVISED	PROPOSED	REVISED	REVISED
		POSITION TITLE, IF AVAILABLE NAME, LICENSE/DEGREE	FY 2023-2024	FY 2023-2024	FTE	FY 2023-2024	FY 2023-2024	SALARY	(FTE, Salary, DSH, and Caseload)	FY 2023-2024	FY 2023-2024	MONTHLY DSH	MONTHLY DSH	vs. PROPOSED	CASELOAD	CASELOAD	vs. PROPOSED
		DIRECT ADMINISTRATION
	1	0.000	0.00		0.00	$0.00		$0.00		$0.00
	2	0.000	0.00		0.00	$0.00		$0.00		$0.00
	3	0.000	0.00		0.00	$0.00		$0.00		$0.00
	4	0.000	0.00		0.00	$0.00		$0.00		$0.00
	5	0.000	0.00		0.00	$0.00		$0.00		$0.00
	6	0.000	0.00		0.00	$0.00		$0.00		$0.00
	7	0.000	0.00		0.00	$0.00		$0.00		$0.00
	8	0.000	0.00		0.00	$0.00		$0.00		$0.00
	9	0.000	0.00		0.00	$0.00		$0.00		$0.00
	10	0.000	0.00		0.00	$0.00		$0.00		$0.00
	11	0.000	0.00		0.00	$0.00		$0.00		$0.00
	12	0.000	0.00		0.00	$0.00		$0.00		$0.00
	13	0.000	0.00		0.00	$0.00		$0.00		$0.00
	14	0.000	0.00		0.00	$0.00		$0.00		$0.00
	15	0.000	0.00		0.00	$0.00		$0.00		$0.00
	16	0.000	0.00		0.00	$0.00		$0.00		$0.00
	17	0.000	0.00		0.00	$0.00		$0.00		$0.00
	18	0.000	0.00		0.00	$0.00		$0.00		$0.00
	19	0.000	0.00		0.00	$0.00		$0.00		$0.00
	20	0.000	0.00		0.00	$0.00		$0.00		$0.00
		Subtotals Direct Administration	0.00	0.00	0.00	$0.00	$0.00	$0.00		$0.00	$0.00

	PROGRAM ADMINISTRATION
1	0.000	0.00		0.00	$0.00		$0.00	$0.00
2	0.000	0.00		0.00	$0.00		$0.00	$0.00
3	0.000	0.00		0.00	$0.00		$0.00	$0.00
4	0.000	0.00		0.00	$0.00		$0.00	$0.00
5	0.000	0.00		0.00	$0.00		$0.00	$0.00
6	0.000	0.00		0.00	$0.00		$0.00	$0.00
7	0.000	0.00		0.00	$0.00		$0.00	$0.00
8	0.000	0.00		0.00	$0.00		$0.00	$0.00
9	0.000	0.00		0.00	$0.00		$0.00	$0.00
10	0.000	0.00		0.00	$0.00		$0.00	$0.00
11	0.000	0.00		0.00	$0.00		$0.00	$0.00
12	0.000	0.00		0.00	$0.00		$0.00	$0.00
13	0.000	0.00		0.00	$0.00		$0.00	$0.00
14	0.000	0.00		0.00	$0.00		$0.00	$0.00
15	0.000	0.00		0.00	$0.00		$0.00	$0.00
16	0.000	0.00		0.00	$0.00		$0.00	$0.00
17	0.000	0.00		0.00	$0.00		$0.00	$0.00
18	0.000	0.00		0.00	$0.00		$0.00	$0.00
19	0.000	0.00		0.00	$0.00		$0.00	$0.00
20	0.000	0.00		0.00	$0.00		$0.00	$0.00
	Subtotals Program Admininstration	0.00	0.00	0.00	$0.00	$0.00	$0.00	$0.00	$0.00

	DIRECT NON-DSH PROGRAM
1	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
2	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
3	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
4	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
5	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
6	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
7	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
8	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
9	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
10	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
11	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
12	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
13	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
14	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
15	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
16	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
17	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
18	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
19	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
20	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
21	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
22	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
23	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
24	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
25	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
26	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
27	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
28	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
29	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
30	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
31	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
32	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
33	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
34	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
35	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
36	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
37	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
38	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
39	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
40	0.000	0.00		0.00	$0.00		$0.00	$0.00		0		0
	Subtotals Direct Non-DSH Program	0.00	0.00	0.00	$0.00	$0.00	$0.00	$0.00	$0.00	0	0	0

	DIRECT DSH PROGRAM (NON-MEDICATION SUPPORT SERVICES)
1	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
2	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
3	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
4	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
5	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
6	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
7	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
8	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
9	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
10	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
11	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
12	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
13	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
14	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
15	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
16	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
17	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
18	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
19	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
20	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
21	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
22	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
23	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
24	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
25	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
26	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
27	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
28	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
29	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
30	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
31	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
32	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
33	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
34	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
35	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
36	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
37	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
38	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
39	0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
40	0.00	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
	Subtotals Direct DSH Program	0.00	0.00	0.00	$0.00	$0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
	(Non-Medication Support Services)

DIRECT DSH PROGRAM (MEDICATION SUPPORT SERVICES*)
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
0.000	0.00		0.00	$0.00		$0.00	$0.00		0	0	0	0		0
Subtotal Direct DSH Program	0.00	0.00	0.00	$0.00	$0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
(Medication Support Services)

	PROGRAM SUBCONTRACTORS
1	0.000	0.00		0.00	$0.00	$0.00	$0.00
2	0.000	0.00		0.00	$0.00	$0.00	$0.00
3	0.000	0.00		0.00	$0.00	$0.00	$0.00
4	0.000	0.00		0.00	$0.00	$0.00	$0.00
5	0.000	0.00		0.00	$0.00	$0.00	$0.00
6	0.000	0.00		0.00	$0.00	$0.00	$0.00
7	0.000	0.00		0.00	$0.00	$0.00	$0.00
8	0.000	0.00		0.00	$0.00	$0.00	$0.00
9	0.000	0.00		0.00	$0.00	$0.00	$0.00
10	0.000	0.00		0.00	$0.00	$0.00	$0.00
11	0.000	0.00		0.00	$0.00	$0.00	$0.00
12	0.000	0.00		0.00	$0.00	$0.00	$0.00
13	0.000	0.00		0.00	$0.00	$0.00	$0.00
14	0.000	0.00		0.00	$0.00	$0.00	$0.00
	Subtotals Non-DSH Subcontractors	0.00	0.00	0.00	$0.00	$0.00	$0.00

	DSH Subcontractors (Non-Medication Support Services)
15	0.000	0.00		0.00	$0.00		$0.00	0	0	0
16	0.000	0.00		0.00	$0.00		$0.00	0	0	0
17	0.000	0.00		0.00	$0.00		$0.00	0	0	0
18	0.000	0.00		0.00	$0.00		$0.00	0	0	0
19	0.000	0.00		0.00	$0.00		$0.00	0	0	0
20	0.000	0.00		0.00	$0.00		$0.00	0	0	0
21	0.000	0.00		0.00	$0.00		$0.00	0	0	0
22	0.000	0.00		0.00	$0.00		$0.00	0	0	0
23	0.000	0.00		0.00	$0.00		$0.00	0	0	0
24	0.000	0.00		0.00	$0.00		$0.00	0	0	0
25	0.000	0.00		0.00	$0.00		$0.00	0	0	0
26	0.000	0.00		0.00	$0.00		$0.00	0	0	0
	Subtotal DSH Subcontractors	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0
	(Non-Medication Support Services)

	DSH Subcontractors (Medication Support Services)
28	0.000	0.00		0.00	$0.00		$0.00	0		0
29	0.000	0.00		0.00	$0.00		$0.00	0		0
30	0.000	0.00		0.00	$0.00		$0.00	0		0
31	0.000	0.00		0.00	$0.00		$0.00	0		0
32	0.000	0.00		0.00	$0.00		$0.00	0		0
33	0.000	0.00		0.00	$0.00		$0.00	0		0
34	0.000	0.00		0.00	$0.00		$0.00	0		0
35	0.000	0.00		0.00	$0.00		$0.00	0		0
36	0.000	0.00		0.00	$0.00		$0.00	0		0
37	0.000	0.00		0.00	$0.00		$0.00	0		0
38	0.000	0.00		0.00	$0.00		$0.00	0		0
39	0.000	0.00		0.00	$0.00		$0.00	0		0
	Subtotal DSH Subcontractors	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0
	(Medication Support Services)

SUMMARY
ADMINISTRATION
Direct Administration	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
Program Administration	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
TOTAL ADMINISTRATION	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0

PROGRAM
Direct Non-DSH Program	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
Direct DSH Program (Non-Medication Support Services)	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
*Direct DSH Program (Medication Support Services)	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
TOTAL PROGRAM	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0

SUBCONTRACTORS
Non-DSH Subcontractors	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
DSH Subcontractors (Non-Medication Support Services)	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
*DSH Subcontractors (Medication Support Services)	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0
TOTAL SUBCONTRACTORS:	0.00	0.00	0.00	$0.00	$0.00	$0.00	0	0	0	0	0	0

TOTAL CONTRACT 0.00 0.00 0.00 $0.00 $0.00 $0.00 0 0 0 0 0 0

DSH STAFF CALCULATION
	FTE	ANNUAL DSH	Modified DSH	If modified please provide supporting documentation:
Mental Health Services	0.00	0
*Medication Support Services	0.00	0
Total Contract DSH Staff	0.00	0	0

*Should only include MD's (Psychiatrists) and Licensed Nurse Practioners.

&"Times,Bold"&8&F &"Times,Bold"&8&P of &N &"Times,Bold"&8Prepared By: Contract Administrator

P1 S&S

SERVICES AND SUPPLIES ANALYSIS

Program Name

Location

FY 2023-2024

	VARIANCE
PROPOSED

Uyeda, Brian: Contract Administrator:

Amounts must match the

original proposal.	REVISED	REVISED
		BUDGET	BUDGET	VS.
		FY 2023-2024	FY 2023-2024	PROPOSED	VARIANCE EXPLANATION

Uyeda, Brian: All variances must be explained and included in this column. Please do not reference line-item variance explanations as being addressed in your narratives.

Variance explanations should be clear and concise. Some examples are as follows:

Office Space - "Increased due to renegotiated lease agreement."

Equipment - "Increased due to 3 new laptop computers for new proposed program staff."

Program Supplies - "Reduced due to historical usage and savings reallocated to Equipment."

Uyeda, Brian: Contract Administrator:

Amounts must match the original proposal. ADMINISTRATIVE SERVICES AND SUPPLIES

Equipment( Lease) (from page 5)	$0	$0	$0
Equipment (Owned) (from page 5)	$0	$0	$0
Office Space (from page 5)	$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
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	$0
0	$0	$0	$0
0	$0	$0	$0
0	$0	$0	$0
0	$0	$0	$0
0	$0	$0	$0
Subtotal Admin. Services & Supplies	$0	$0	$0

PROGRAM SERIVCES AND SUPPLIES

Equipment( Lease) (from page 5)	$ - 0	$0	$0
Equipment (Owned) (from page 5)	$ - 0	$0	$0
Office Space (from page 5)	$ - 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
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	$0
0	$ - 0	$0	$0
0	$ - 0	$0	$0
0	$ - 0	$0	$0
0	$ - 0	$0	$0
Subtotal Program Services & Supplies	$0	$0	$0

Flex Fund Detail (For MHSA Agreements only)
Housing	$ -	$0	$0
Transportation	$ -	$0	$0
Food	$ -	$0	$0
Education	$ -	$0	$0
Employment	$ -	$0	$0
Health	$ -	$0	$0
Clothing	$ -	$0	$0
Enrichment Activities	$ -	$0	$0
Residential Treatment	$ -	$0	$0
Miscellaneous/Other	$ -	$0	$0
Other __________________	$ -	$0	$0
Flex Fund Totals	$0	$0	$0

&"Times,Bold"&8&F &"Times,Bold"&8&P of &N &"Times,Bold"&8Prepared By: Contract Administrator

P1 Start-Up

Start-Up Costs

Program Name

Location

FY 2023-2024

	VARIANCE
PROPOSED

Uyeda, Brian: Contract Administrator:

Amounts must match the original proposal.		REVISED	REVISED
				BUDGET	BUDGET	VS.
	ADMINISTRATIVE COSTS

Uyeda, Brian: Contract Administrator:

Titles must match the original proposal. FY 2023-2024 FY 2023-2024 PROPOSED VARIANCE EXPLANATION Uyeda, Brian: All variances must be explained and included in this column.

Variance explanations should be clear and concise. Some examples are as follows:

Office Space - "Increased due to renegotiated lease agreement since proposal was submitted."

Equipment - "Increased due to 3 new laptop computers for additional proposed 3.0 FTE program staff."

Program Supplies - "Increased due to additional proposed 3.0 FTE program staff."

Uyeda, Brian: Contract Administrator:

Titles must match the original proposal.

Uyeda, Brian: Contract Administrator:

Amounts must match the original proposal.	Salaries	-	$0	$0
	Benefits	-	$0	$0
	Indirect	-	$0	$0
	Sub Total Administration	$0	$0	$0

Services and Supplies
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
Sub Total Admin. Services & Supplies	$0	$0	$0

Subtotals Admininistrative Start-up Costs $0 $0 $0

PROGRAM COSTS
Salaries	-	$0	$0
Benefits	-	$0	$0
Indirect	-	$0	$0
Sub Total Program	$0	$0	$0

Services and Supplies
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	$0
0	-	$0	$0
0	-	$0	$0
0	-	$0	$0
Sub Total Program Services and Supplies	$0	$0	$0
Subtotals Program Start-up Costs	$0	$0	$0

Grand Total Start-up Costs $0 $0 $0

CA Analysis Notes

Location

CA Analysis Renewal Notes

&"Times,Bold"&8&F &"Times,Bold"&8&P of &N &"Times,Bold"&8Prepared By: Contract Administrator

Proposed Summary

		DUE DATE:	October 19, 2023
CONTRACT BUDGET PROPOSAL PACKAGE
	JULY 1, 2024 - JUNE 30, 2025

				PROGRAM SUMMARY
TO:	Roosevelt McCombs	FROM:
	CONTRACT SERVICES		(Contractor's Corporate Name as Listed on Articles of Incorporation)
	ORANGE OF COUNTY HEALTH CARE AGENCY
	405 W. 5th St, Suite 600		(Street Address of Admin. Offices)
	SANTA ANA, CA 92701
			(City, State, Zip Code)		(Telephone)
NOTE: This document contains automatic links.
Enter values/information only into the GREEN SHADED areas			(Profit/Non-Profit/Other)

TYPE OF CONTRACT: Actual Cost Reimbursement

		PROGRAM	ADMIN	FY 2023-2024	FY 2023-2024
		FTE	FTE	TOTAL PROPOSED	TOTAL REVISED
NAME AND LOCATION	Services(*)	STAFF	STAFF	BUDGET	COSTS

0
Program Name	Prevention and Intervention	0.00	0.00	$0	$0
Location

GRAND TOTALS: 0.00 0.00 $0 $0

SERVICES (*)		Select	BEHAVIORAL_HEALTH	PUBLIC_HEALTH	CORRECTIONAL_HEALTH	MEDICAL_SERVICES	SUBSTANCE_USE_DISORDER
Area:			1) Outpatient	1) ADEPT	1) Radiology	1) MSI	1) PSN
Prevention and Intervention	AUTHORIZED SIGNATURE		2) Full Service Partnership	2) TUPP		2) EMSF	2) Post Custody
Program:			3) Wraparound	3) HIV Care Srvs (Specify below)		3) HDM	3) Sober Living
Prevention and Intervention	The undersigned hereby acknowledges: "I have read and understand the contents of the		4) In-Home Crisis Stabilization	4) HIV Prevention (Specify below)		4) Ambulance	4) AB 109
	attached budget request for County funding for the contract period specified above.		5) Crisis Residential	5) HIV Specialty Srv. (Specify below)		5) CCS	5) Narcotic Repl.
	It is correct to the best of my knowledge and represents the organization's proposal for		6) Outreach & Engagement	6) Communicable Disease Services			6) Straight Talk
	the provision of services to the County. I also hereby certify that I have the authority to submit		7) Prevention & Intervention	7) Nutrition Services			7) Res. Recovery
	this information on behalf of the organization".		8) Supported Employment	8) Other (Specify below)			8) Res Recov. & Detox
			9) Multi-Service Center				9) Outpatient Services

		10) Training	10) CalWORKS
Authorized Representative	Date	11) Mentoring
		12) CalWorks
		13) SSI Outreach
		14) Representative Payee
		15) Patient Advocate
		16) Other (specify below)

&"Times,Bold"&8&F &"Times,Bold"&8&P of &N &"Times,Bold"&8Prepared By: Contract Administrator

Proposed Budget

	Due Date:	October 19, 2023
CONTRACT BUDGET PACKAGE
JULY 1, 2024 - JUNE 30, 2025

TO:	Roosevelt McCombs	FROM:	0
	CONTRACT SERVICES		(Corporate Name as Listed on Articles of Incorporation)
	HEALTH CARE AGENCY
	405 W. 5th St, Suite 600		(Street Address of Admin. Offices)
	SANTA ANA, CA 92701
			(City, State, Zip Code)	(Telephone)
			UEI# by Location

Daniel Vu: Daniel Vu:

UNIQUE ENTITY IDENTIFIER

Tax ID#

NPI #

NOTE: This document contains automatic links.					FY 2023-2024	FY 2023-2024
Enter values/information into the GREEN SHADED areas only
			PROGRAM	ADMIN	CONTRACT	CONTRACT
	PROGRAM NAME		FTE STAFF	FTE STAFF	TOTAL PROPOSED	TOTAL REVISED
	AND LOCATION	SERVICES	PROPOSED	PROPOSED	BUDGET	COSTS

0 Prevention and Intervention 0.00 0.00 $0 $0

	Program Name
	Location
	Enter CFDA# (If Applicable or indicate NA)
BUDGET SUMMARY
12 MONTH REQUESTED BUDGET
JULY 1, 2024 - JUNE 30, 2025
	PROVIDER:	0
		(Corporate Name as Listed on Articles of Incorporation)

(Street Address of Admin. Offices)

	(City, State, Zip Code)		(Telephone)
				PROPOSED
I. ADMINISTRATION COSTS				TOTAL
	A. Salaries			$0
	B. Benefits			$0
	C. Services and Supplies			$0
	D. Professional Services Costs
	E. Indirect Costs
		F. Subtotal (I.A. thru E.) **		$0

** (Administration Costs cannot exceed a maximum of 15%, or as directed by Funding Source of total Program costs)

II. PROGRAM COSTS
	A. Salaries		$0
	B. Benefits		$0
	C. Services and Supplies		$0
	D. Subcontractor Costs		$0
	E. Flexible Funds		$0
	F. Start-Up Funds		$0
		G. Subtotal (II.A. thru F.)	$0

III. TOTAL COSTS (I.F. + II.F.) $0

IV. REVENUE FUNDING $0

V. NET COST (III. - IV.) $0

VI. CONTRACT AMOUNT	Gross Cost	$0
	Net Cost	$0

ADMINISTRATIVE SERVICES AND SUPPLIES DETAIL

PROVIDER:	0
PROGRAM NAME:	Program Name
LOCATION:	Location

NOTE: INCLUDE ADMINISTRATION COSTS ONLY. DO NOT INCLUDE DIRECT PROGRAM COSTS.

	FY 2023-2024
	TOTAL PROPOSED
SERVICES AND SUPPLIES	BUDGET

1	Equipment( Lease) (from page 5)		$ - 0
2	Equipment (Owned) (from page 5)		$ - 0
3	Office Space (from page 5)		$ - 0
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
		SERVICES AND SUPPLIES SUBTOTAL	$ - 0

* Indicate your food cost per client per day if applicable:

** Indicate your reimbursement rate per mile:

PROGRAM SERVICES AND SUPPLIES DETAIL

	PROVIDER:	0
	PROGRAM NAME:	Program Name
	LOCATION:	Location
NOTE: DO NOT INCLUDE ADMINISTRATION COSTS. INCLUDE DIRECT PROGRAM COSTS ONLY.

	FY 2023-2024
	TOTAL PROPOSED
SERVICES AND SUPPLIES	BUDGET

1	Equipment( Lease) (from page 5)		$ - 0
2	Equipment (Owned) (from page 5)		$ - 0
3	Office Space (from page 5)		$ - 0
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
		SERVICES AND SUPPLIES SUBTOTAL	$ - 0

* Indicate your food cost per client per day if applicable:

** Indicate your reimbursement rate per mile:

		FY 2023-2024
		REQUESTED
***	Flex Fund Detail (For MHSA Agreements only)	BUDGET

1	Housing
2	Transportation
3	Food
4	Education
5	Employment
6	Health
7	Clothing
8	Enrichment Activities
9	Residential Treatment
10	Miscellaneous/Other
11	Other __________________
	Flex Fund Totals	$0

*** Discuss with Contract Administrator if you have any questions.

FY 2023-2024

Wheeler, Vicki: Wheeler, Vicki:

If Proposed Services will not have Start-Up Funding Lines 195 thru 249 should be hid.	REQUESTED
		Start-Up Details	BUDGET

	Administration
1	Salaries	-
2	Benefits
3	Indirect
	Sub Total Administration	$0

	Services and Supplies
4		-
5
6
7
8
9
10
11
12
13
	Sub Total Admin. Services & Supplies	$0
	Total Administration Start-up	$0

	Program
1	Salaries	-
2	Benefits
3	Indirect
	Sub Total Program	$0

	Services and Supplies
4		-
5
6		-
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
	Sub Total Program Services & Supplies Start-up	$0
	Subtotals Program Start-up Costs	$0

Grand Total Start-up Costs $0

REVENUE DETAIL

INDICATE BUDGETED REVENUE AND EXPLAIN THE BASIS FOR THESE PROJECTIONS.

			Amount
	FY 2023-2024	FY 2023-2024	of
	Budgeted	Proposed	Increase	%
	Revenue	Revenue	(Decrease)	Change
CLIENT FEES	$ -	$ - 0	$ - 0	0.0%
RESIDENTIAL/PARTICIPANT FEES	$ -	$ - 0	$ - 0	0.0%
INSURANCE	$ -	$ - 0	$ - 0	0.0%
MEDI-CAL (FFP and State Match)	$ -	$ - 0	$ - 0	0.0%
MEDICARE	$ -	$ - 0	$ - 0	0.0%
FOOD STAMPS	$ -	$ - 0	$ - 0	0.0%
DONATIONS	$ -	$ - 0	$ - 0	0.0%
SDI	$ -	$ - 0	$ - 0	0.0%
OTHER (County Discretionary)	$ -	$ - 0	$ - 0	0.0%
OTHER (MHSA)	$ -	$ - 0	$ - 0	0.0%
TOTAL REVENUE	$0	$0	$ - 0	0.0%

UNRESTRICTED DONATIONS:	$ -	$ - 0	$ - 0
% CLIENTS MEDI-CAL ELIGIBLE:	0.0%	0.0%	0.0%

REMARKS:

FACILITY EXPENSE DETAIL

PROVIDER:	0
PROGRAM NAME:	Program Name
LOCATION:	Location

OFFICE SPACE

In the space below, describe the basis for budgeting costs of program facilities and office space. Include leases, mortgages, and

property tax as applicable. If an allocation is made between the program(s) applied for herein and another program, indicate

the basis for this allocation. Costs should reflect annualized amounts.

FY 2023-2024
		Total	Proposed
Location		Facility	Allocation
	GROSS SQUARE FOOTAGE			MORTGAGE INTEREST
	LEASE/RENT EXPENSE			PROPERTY TAXES
	GROSS SQUARE FOOTAGE			MORTGAGE INTEREST
	LEASE/RENT EXPENSE			PROPERTY TAXES
	GROSS SQUARE FOOTAGE			MORTGAGE INTEREST
	LEASE/RENT EXPENSE			PROPERTY TAXES
	GROSS SQUARE FOOTAGE			MORTGAGE INTEREST
	LEASE/RENT EXPENSE			PROPERTY TAXES
			FY 2023-2024
		Total Contract Cost	$0

Administrative Costs	$0
Program Costs	$0
Other_______	$0
Total Cost	$0

EQUIPMENT OWNED & LEASE DETAIL

List the item description, original cost, and useful life of any item purchased for $2,000 or more that you will be depreciating or

charging to the County contract.

					Amount
		OWNED			to be
	Purchase	or	ORIGINAL	USEFUL	Charged
ITEM	Date	LEASED	COST	LIFE	FY 2023-2024
			-	-
			-	-

	FY 2023-2024
Administrative Amount Owned to be Charged
Administrative Amount of Leased Equipment Expense
Program Amount Owned to be or Charged
Program Amount of Leased Equipment Expense
Total Contract Cost	$0

FINANCIAL/ACCOUNTING INFORMATION

PROVIDER:	0
PROGRAM NAME:	Program Name	Select	Select
LOCATION:	Location	Cash	Yes

Describe your accounting method (select one from drop down box):		Accrual	No
		Modified Accrual
	Select

NOTE: Any change in your accounting method over the past year or since last renewal must be carefully considered and requires notification be sent to Contract Administrator.
	Please use remark section below.

LICENSES, PERMITS, APPROVALS

PROVIDER:	0
PROGRAM NAME:	Program Name
LOCATION:	Location

Does your program require a Conditional Use Permit (CUP)? (check one):	Select
Expiration Date:

REMARKS:

Facility is located in a zone.

Do you plan to provide services at any new locations? If so, explain where and give zone and CUP or variance information.

State Certification Expiration Date:

Provisional: Unconditional:

If Residential Facility:

Type of License: Expiration Date:

Food Stamp Certification

Expiration Date:

&"Times,Bold"&8&F &"Times,Bold"&8&P of &N &"Times,Bold"&8Prepared By: Contract Administrator

Proposed Staffing

Program Name

Location

TOTAL

TITLE OF POSITION,

HRs Per

FTE

Monthly

Hourly

Monthly

Percent of

Monthly

Annual

Percent of

Monthly

(IF AVAILABLE NAME OF EMPLOYEE)

Week

percent

Proposed

Salary for

Benefits for

Rate for

Salary for

These Srvc.

Benefits for

Benefits to

Proposed

(IF AVAILABLE LICENSE/DEGREE)

This Program

equivalent

DSH

This Program

All Prgrms.

Annual Salary

Caseload

DIRECT ADMINISTRATION

Wheeler, Vicki: Wheeler, Vicki:

Depending on Services some of the Staffing Categories below may be hid

			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
1
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
2
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
3
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
4
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
5
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
6
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
7
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
8
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
9
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
10
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
11
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
12
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
13
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
14
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
15
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
16
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
17
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
18
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
19
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
20
	Subtotals	0.00	0.00	0.00	$0.00	$0.00	N/A	$0.00	0%	N/A	$0.00	0.0%

													Monthly
													Proposed
	PROGRAM ADMINISTRATION												Caseload
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
1
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
2
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
3
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
4
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
5
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
6
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
7
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
8
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
9
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
10
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
11
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
12
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
13
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
14
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
15
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
16
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
17
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
18
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
19
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	N/A
20
	Subtotals	0.00	0.00	0.00	$0.00	$0.00	N/A	$0.00	0%	N/A	$0.00	0.0%

													Monthly
													Proposed
	Direct Non-DSH PROGRAM:												Caseload
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
1
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
2
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
3
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
4
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
5
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
6
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
7
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
8
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
9
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
10
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
11
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
12
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
13
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
14
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
15
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
16
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
17
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
18
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
19
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
20
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
21
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
22
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
23
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
24
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
25
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
26
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
27
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
28
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
29
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
30
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
31
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
32
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
33
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
34
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
35
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
36
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
37
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
38
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
39
			0.00	N/A	$0.00	$0.00			0%		$0.00	0.0%	0.00
40
	Subtotals	0.00	0.00	0	$0.00	$0.00	N/A	$0.00	0%	N/A	$0.00	0.0%	0.00

													Monthly
	DIRECT DSH PROGRAM (NON-MEDICATION SUPPORT SERVICES)												Proposed Caseload
			0.00		$0.00	$0.00	- 0		0%		$0.00	0.0%	0.00
1
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
2
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
3
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
4
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
5
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
6
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
7
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
8
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
9
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
10
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
11
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
12
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
13
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
14
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
15
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
16
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
17
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
18
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
19
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
20
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
21
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
22
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
23
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
24
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
25
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
26
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
27
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
28
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
29
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
30
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
31
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
32
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
33
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
34
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
35
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
36
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
37
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
38
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
39
			0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
40
	Subtotals	0.00	0.00	0	$0.00	$0.00	N/A	$0.00	0%	N/A	$0.00	0.0%	0.00

														Monthly
		DIRECT DSH PROGRAM (MEDICATION SUPPORT SERVICES)
Uyeda, Brian: This section is only for Non-Subcontract Psychiatrists and Licensed Nurse Practioners providing Medication Support Services.												Proposed Caseload
				0.00		$0.00	$0.00			0%		$0.00	0.0%	0.00
	1
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	2
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	3
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	4
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	5
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	6
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	7
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	8
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	9
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	10
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	11
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	12
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	13
				0.00		$0.00	$0.00			0%	$ - 0	$0.00	0.0%	0.00
	14
		Subtotals	0.00	0.00	0	$0.00	$0.00	N/A	$0.00	0%	N/A	$0.00	0.0%	0

		SUBCONTRACTS:
		Non-DSH Subcontractors
Uyeda, Brian: This section is for all Non-DSH producing subcontractors, including Psychiatrists that provide Non-Medication Support Services (i.e., administrative activities such as staff supervision/training).	POSITION OR AGENCY:		Total Annual Hours	FTE	Rate Per Hr.	Annual Cost	Monthly Cost	Monthly DSH
	1				0	0.00	$ - 0	$0.00	$0.00	N/A
	2				0	0.00	$ - 0	$0.00	$0.00	N/A
	3				0	0.00	$ - 0	$0.00	$0.00	N/A
	4				0	0.00	$ - 0	$0.00	$0.00	N/A
	5				0	0.00	$ - 0	$0.00	$0.00	N/A
	6				0	0.00	$ - 0	$0.00	$0.00	N/A
	7				0	0.00	$ - 0	$0.00	$0.00	N/A
	8				0	0.00	$ - 0	$0.00	$0.00	N/A
	9				0	0.00	$ - 0	$0.00	$0.00	N/A
	10				0	0.00	$ - 0	$0.00	$0.00	N/A
	11				0	0.00	$ - 0	$0.00	$0.00	N/A
	12				0	0.00	$ - 0	$0.00	$0.00	N/A
	13				0	0.00	$ - 0	$0.00	$0.00	N/A
	14				0	0.00	$ - 0	$0.00	$0.00	N/A
		Subtotals Non-DSH Subcontractors			0	0.00	N/A	$0.00	$0.00	N/A

DSH Subcontractors (Non-Medication Support Services) Uyeda, Brian: This section is for all DSH producing subcontractors, excluding subcontractors providing Medication Support Services.

POSITION OR AGENCY:		Total Annual Hours	FTE	Rate Per Hr.	Annual Cost	Monthly Cost	Monthly DSH
17				0	0.00	$ - 0	$0.00	$0.00	0
18				0	0.00	$ - 0	$0.00	$0.00	0
19				0	0.00	$ - 0	$0.00	$0.00	0
20				0	0.00	$ - 0	$0.00	$0.00	0
21				0	0.00	$ - 0	$0.00	$0.00	0
22				0	0.00	$ - 0	$0.00	$0.00	0
23				0	0.00	$ - 0	$0.00	$0.00	0
24				0	0.00	$ - 0	$0.00	$0.00	0
25				0	0.00	$ - 0	$0.00	$0.00	0
26				0	0.00	$ - 0	$0.00	$0.00	0
27				0	0.00	$ - 0	$0.00	$0.00	0
28				0	0.00	$ - 0	$0.00	$0.00	0
	Subtotals DSH Subcontractors (Non-Medication Support Services)			0	0.00	N/A	$0.00	$0.00	0

DSH Subcontractors (Medication Support Services) Uyeda, Brian: This section is only for subcontractors providing Medication Support Services (i.e., Psychiatrists and Licensed Nurse Practioners).

Uyeda, Brian: This section is for all DSH producing subcontractors, excluding subcontractors providing Medication Support Services.

POSITION OR AGENCY:		Total Annual Hours	FTE	Rate Per Hr.	Annual Cost	Monthly Cost	Monthly DSH
31				0	0.00	$ - 0	$0.00	$0.00	0
32				0	0.00	$ - 0	$0.00	$0.00	0
33				0	0.00	$ - 0	$0.00	$0.00	0
34				0	0.00	$ - 0	$0.00	$0.00	0
35				0	0.00	$ - 0	$0.00	$0.00	0
36				0	0.00	$ - 0	$0.00	$0.00	0
37				0	0.00	$ - 0	$0.00	$0.00	0
38				0	0.00	$ - 0	$0.00	$0.00	0
40				0	0.00	$ - 0	$0.00	$0.00	0
41				0	0.00	$ - 0	$0.00	$0.00	0
42				0	0.00	$ - 0	$0.00	$0.00	0
43				0	0.00	$ - 0	$0.00	$0.00	0
	Subtotals DSH Subcontractors (Medication Support)			0	0.00	N/A	$0.00	$0.00	0
	Total Subcontractors			0.00	0.00	N/A	$0.00	$0.00	0

DIRECT ADMINISTRATION TOTALS:	0.00	0.00	0.00	$0.00	$0.00
DIRECT NON-DSH & DSH PROGRAM TOTALS:	0.00	0.00	0.00	$0.00	$0.00
INDIRECT COSTS:	N/A	N/A	N/A	N/A	N/A
SUBCONTRACTS:	N/A	0.00	0.00	$0.00	N/A
TOTALS:	0.00	0.00	0.00	$0.00	$0.00

HRs Per	FTE	Monthly	Monthly	Monthly
Week	percent	Proposed	Salary for	Benefits for
This Program	equivalent	DSH	This Program	This Program

&"Times,Bold"&8&F &"Times,Bold"&8&P of &N &"Times,Bold"&8Prepared By: Contract Administrator image3.emf image1.emf image2.emf image4.emf image8.emf image9.emf image5.emf image6.emf image7.emf

File details come from the government source that posted it. Updated May 12, 2025.