CTR057399_Contract_Amendment_4_.pdf
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- Attached to
- Master Agreement AZ|CTR057399
- Contract number
- CTR057399
- Issued by
- Arizona
About this file
This document is a Contract Amendment issued by the Arizona Department of Economic Security (ADES) for contract CTR057399, specifically Amendment Number Four, involving Maricopa County Special Health Care District (dba Valleywise Health). The amendment pertains to the Refugee Program - Health Promotion service and covers the contract period from October 1, 2023, through September 30, 2024.
The amendment establishes a total contract reimbursement ceiling of $208,245.46, with a detailed budget breakdown across multiple cost categories. Key budget components include personnel costs of $160,095.94 (covering 1.75 FTE for a Community Health Nurse and 0.5 FTE for an Administrative Assistant), professional services totaling $4,200.00 (including Mental Health Wellness Trainer and Community Mobilizers), travel expenses of $1,500.42, and operating services of $800.00 for monthly cellphone charges. The budget also includes $41,649.09 in indirect costs, calculated at 25% for employment and other categories. The contract is fully funded by the ADES Refugee Program, with the total allocation precisely matching the total costs.
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Text version
CONTRACT AMENDMENT
Arizona Department of Economic Security
1789 W Jefferson Street, Mail Drop 1541, Phoenix, AZ 85007
CONTRACT NUMBER: AMENDMENT NUMBER:
CTR057399 Four (4)
DESCRIPTION/ LABEL: Refugee Program - Health Promotion
CONTRACTOR NAME: Maricopa County Special Health Care District
THE ABOVE REFERENCED CONTRACT IS HEREBY MODIFIED AS FOLLOWS:
In accordance with the Special Terms and Conditions, Section 28, Levels of Service, the purpose of this amendment is to revise the Itemized Service Budget for the period of October 1, 2023 through September 30, 2024. The contract reimbursement ceiling is $208,245.46.
The Itemized Service Budget is attached as part of this amendment.
ALL OTHER REQUIREMENTS, SPECIFICATIONS, AND TERMS AND CONDITIONS REMAIN UNCHANGED
ACKNOWLEDGEMENT AND AUTHORIZATION
This Amendment shall be fully executed by means of electronic approval in APP.
Funding: Health Promotion Service: CRD-RRP-HPR Contract #: CTR057399
Total Allocation: $208,245.46 Contract Period: 10/01/2023-09/30/2024
Indirect Cost Eligible (dropdown)
Cost Category (dropdown) FTE Level Position Title
Total Salary for the Contract Period per FTE ERE Rate
% Billed to this Contract Personnel Subtotal
Employee Related Expenses Subtotal Total Cost
Yes Employment 1.75 CHN $98,477.60 32.00% 57% $98,477.60 $31,512.83 $129,990.44 Yes Employment 0.5 Administrative Assistant $22,807.20 32.00% 200% $22,807.20 $7,298.30 $30,105.50
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
TOTAL PERSONNEL & ERE: $121,284.80 $38,811.14 $160,095.94
Indirect Cost Eligible (dropdown)
Cost Category (dropdown) Total Units Unit (dropdown) Unit description Rate per Unit
Number of reoccurrences
Rate of reoccurrence (dropdown) Total Cost
Yes Other 4 Hour Mental Health Wellness Trainer $250.00 1 Day $1,000.00 Yes Other 128 Hour Community Mobilizers $25.00 1 Month $3,200.00
$0.00 $0.00 $0.00
TOTAL PROFESSIONAL AND OUTSIDE SERVICES: $4,200.00
Indirect Cost Eligible (dropdown)
Cost Category (dropdown) Total Units Unit (dropdown) Unit description Rate per Unit
Number of reoccurrences
Rate of reoccurrence (dropdown) Total Cost
Yes Employment 2,290.72 Mile Mileage $0.66 1 Month $1,500.42
$0.00 $0.00
ATTACHMENT 13-B
ITEMIZED SERVICE BUDGET
1. PERSONNEL & ERE
2. PROFESSIONAL AND OUTSIDE SERVICES
3. TRAVEL
Agency: Maricopa County Special Health dba Valleywise Health
Revised 3.26.13
TOTAL TRAVEL: $1,500.42
Indirect Cost Eligible (dropdown)
Cost Category (dropdown) Total Units Unit (dropdown) Unit description Rate per Unit
Number of reoccurrences
Rate of reoccurrence (dropdown) Total Cost
$0.00 $0.00 $0.00
TOTAL SPACE: $0.00
Indirect Cost Eligible (dropdown)
Cost Category (dropdown) Total Units Unit (dropdown) Unit description Rate per Unit
Number of reoccurrences
Rate of reoccurrence (dropdown) Total Cost
$0.00
$0.00
TOTAL EQUIPMENT: $0.00
Indirect Cost Eligible (dropdown)
Cost Category (dropdown) Total Units Unit (dropdown) Unit description Rate per Unit
Number of reoccurrences
Rate of reoccurrence (dropdown) Total Cost
$0.00 $0.00
TOTAL MATERIALS AND SUPPLIES: $0.00
Indirect Cost Eligible (dropdown)
Cost Category (dropdown) Total Units Unit (dropdown) Unit description Rate per Unit
Number of reoccurrences
Rate of reoccurrence (dropdown) Total Cost
Yes Other 15.3847 Other Monthly Cellphone Charge $52.00 1 Month $800.00 $0.00 $0.00 $0.00 $0.00
4. SPACE
5. EQUIPMENT
6. MATERIALS AND SUPPLIES
7. OPERATING SERVICES
TOTAL OPERATING SERVICES: $800.00
Cost Category Total costs eligible for
Indirects Indirect % Total Cost Not Applicable -$ $0.00 Case Management -$ $0.00 Employment 161,596.36$ 25.00% $40,399.09 Admin -$ $0.00 Other 5,000.00$ 25.00% $1,250.00
TOTAL INDIRECT COSTS: $41,649.09
Cost Category (dropdown) Total Units Unit (dropdown) Unit description Rate per Unit
Number of reoccurrences
Rate of reoccurrence (dropdown) Total Cost
$0.00 $0.00
TOTAL CLIENT DIRECT SERVICES: $0.00
Total Cost
Personnel $121,284.80
ERE $38,811.14
Professional & Outside Services $4,200.00 Travel $1,500.42 Space $0.00
Equipment $0.00
Materials & Supplies $0.00 Operating Services $800.00
Indirect Costs $41,649.09
Client Direct Services/Vouchers $0.00
TOTAL COSTS: $208,245.46
Revenue: Total Cost
9. INDIRECT COSTS
10. CLIENT DIRECT SERVICES/VOUCHERS
If there are no Indirect Costs, please provide an explanation/details in this box
ADES Refugee Program $208,245.46
TOTAL REVENUE: $208,245.46
Budget Check:
Total Allocation $208,245.46
Total Revenue ADES Cost $208,245.46 (Should equal zero) $0.00
| ADPB045.tmp |
| Original ISB |
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