CTR057399_Contract_Amendment_6.pdf
PDF 132 KB Posted
- Attached to
- Master Agreement AZ|CTR057399
- Contract number
- CTR057399
- Issued by
- Arizona
About this file
This is a Contract Amendment issued by the Arizona Department of Economic Security (ADES) for Contract Number CTR057399, Amendment Number Six, involving Maricopa Special Health Care District, doing business as Valleywise Health Grants. The amendment is specifically for the Refugee Program - Health Promotion and is between the state agency and the healthcare organization.
The contract amendment establishes a total allocation of $200,000.00 for the contract period of October 1, 2024 through September 30, 2025. The budget breakdown includes personnel costs totaling $154,200.00, with 2.5 FTE for a Community Health Nurse and 0.6 FTE for an Administrative Assistant. Additional budget categories include $3,200.00 for professional services (community mobilizers), $800.00 for travel, $1,800.00 for operating services (monthly cellphone charges), and $40,000.00 in indirect costs. The contract is fully funded by the ADES Refugee Program, with the budget balanced to exactly match the total allocation, and includes a 25% indirect cost rate for employment and other categories.
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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 Six [6]
DESCRIPTION/ LABEL: Refugee Program - Health Promotion
CONTRACTOR NAME: Maricopa Special Health Care District, DBA Valleywise Health Grants
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, 2024 through September 30, 2025. The contract reimbursement ceiling is $200,000.00
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 Agency: Valleywise Health
Service: CRD-RRP-HPR Contract #: CTR057399
Total Allocation: $200,000.00 Contract Period: 10/01/24-09/30/25
Agency UEI#: J2RHHVGKRH11
Voucher/Client Direct Svcs eligible (Y/N): N
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 2.5 CHN $61,942.40 32.00% 59.32% $91,858.18 $29,394.62 $121,252.80
Yes Employment 0.6 Administrative Assistant $41,600.00 32.00% 100.00% $24,960.00 $7,987.20 $32,947.20
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00
$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: $116,818.18 $37,381.82 $154,200.00
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 Other 128 Hour Community Mobilizers $25.00 1 Month $3,200.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTAL PROFESSIONAL AND OUTSIDE SERVICES: $3,200.00
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 Other 1221.38 Mile Mileage $0.66 1 Month $800.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTAL TRAVEL: $800.00
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
$0.00
$0.00
$0.00
ATTACHMENT
ITEMIZED SERVICE BUDGET
1. PERSONNEL & ERE
2. PROFESSIONAL AND OUTSIDE SERVICES
3. TRAVEL
4. SPACE
Revised 3.26.13
$0.00
$0.00
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$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 34.6154 Other Monthly Cellphone Charge $52.00 1 Month $1,800.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTAL OPERATING SERVICES: $1,800.00
Cost Category
Total costs eligible for
Indirects Indirect % Total Cost
Not Applicable -$ $0.00
Case Management -$ $0.00
Employment 154,200.00$ 25.00% $38,550.00
Admin -$ $0.00
Other 5,800.00$ 25.00% $1,450.00
5. EQUIPMENT
6. MATERIALS AND SUPPLIES
7. OPERATING SERVICES
8. INDIRECT COSTS
If there are no Indirect Costs, please provide an explanation/details in this box
TOTAL INDIRECT COSTS: $40,000.00
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
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTAL CLIENT DIRECT SERVICES: $0.00
Total Cost
Personnel $116,818.18
ERE $37,381.82
Professional & Outside Services $3,200.00
Travel $800.00
Space $0.00
Equipment $0.00
Materials & Supplies $0.00
Operating Services $1,800.00
Indirect Costs $40,000.00
Client Direct Services/Vouchers $0.00
TOTAL COSTS: $200,000.00
Revenue: Total Cost
ADES Refugee Program $200,000.00
TOTAL REVENUE: $200,000.00
Budget Check:
Total Allocation $200,000.00
Total Revenue ADES Cost $200,000.00
(Should equal zero) $0.00
9. CLIENT DIRECT SERVICES/VOUCHERS
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