ESBD_393327_1738102067374_FFY25 Uniform Rate Negotiation Budget Workbook.xlsm

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Attached to
RFP-25-04-AAA-Meal Delivery Service Provider
Solicitation number
RFP25-04-AAA
Issued by
Grimes County, Texas

About this file

Written by GovTribe AI ·

This is a Federal Fiscal Year 2025 Uniform Rate Negotiation Budget Workbook from Texas Health and Human Services for nutrition providers, covering the contract period of October 1, 2024 through September 30, 2025. The workbook is designed to capture detailed budget information for home-delivered meals, congregate meals, participant assessment, and transportation services. The document requires providers to specify their service delivery information, including the number of meal routes, preparation sites, and whether they serve meals at least 5 days a week and 250 days per year.

The workbook contains detailed budget worksheets that break down costs into categories including personnel, professional development, meals/food, equipment, occupancy/building, transportation/travel, and administrative expenses. Each service type has its own budget calculation section with specific match requirements - 10% for some services and 25% for others. The document includes a projected NSIP (Nutrition Services Incentive Program) per meal value of $0.73 and notes that for common providers, the unit rate cannot exceed $6.46 as of May 26, 2023. The workbook also includes provisions for in-kind match certifications and requires detailed documentation for any in-kind contributions following IRS Publication 561 requirements.

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Other files

File Type Posted
ESBD_393327_1738100614531_RFP-FY25 Meal Service Provider - Alamo AAA.ProgramFinal.1.28.25.pdf PDF
ESBD_393327_1738948520326_Responses RFP-25-04-AAA-Meal Delivery Service Provider-AMBMON docx.docx DOCX document
ESBD_393327_1738102067374_FFY25 Uniform Rate Negotiation Budget Workbook.xlsm XLSM spreadsheet
ESBD_393327_1738948520326_Responses RFP-25-04-AAA-Meal Delivery Service Provider-AMBMON docx.docx DOCX document
ESBD_393327_1738100614531_RFP-FY25 Meal Service Provider - Alamo AAA.ProgramFinal.1.28.25.pdf PDF

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Provider Information

2/28/2024 10:16 AMSubmission #101ƒ
Texas Health and Human Services
Uniform Rate Negotiation Workbook/Budget
Federal Contract Period:10-01-24 / 09-30-25
1Nutrition Providers Legal Business Name:
2Street Address:
3Mailing Address:
4City:
5Zip Code:
6Phone Number:
7E-mail Address:
8Contact Name:
9Nutrition Providers website address:
10Did this Nutrition provider complete a rate setting workbook last year?Either Yes or No must be selected
11If Yes, what was the provider name listed on the workbook?
12Is the Provider a AAA Provider?Either Yes or No must be selectedEither Yes or No must be selectedEither Yes or No must be selected
13If Yes, select the AAA Name:
14If Yes, contact name at AAA:
15If Yes, is it a contract or subrecipient?
16Is the Provider a HHS Contracted Community Services Provider?Either Yes or No must be selectedEither Yes or No must be selectedEither Yes or No must be selected
17If Yes, Contract Manager name at HHS Contracted Community Services:NA
18If Yes, select the HHS Region Number:
19If Yes, enter the HHS contract number:
Service Delivery Information
Home Delivered Meals
20Does this Nutrition provider serve home delivered meals paid for by HHS or the AAA?Either Yes or No must be selectedEither Yes or No must be selected
21Does this Nutrition provider have an approved Home Delivered Nutrition Waiver for 2022?NA
22Is this Nutrition provider requesting a Home Delivered Nutrition Program Approval for 2023?NA
23Total number of home delivered meal routes for this provider:
24Total number of meal preparation sites used by this provider:
25Does the provider make home delivered meals available at least 5 days a week and 250 days a year?
Congregate Meals
26Does this Nutrition provider serve congregate meals paid for by the AAA?Either Yes or No must be selectedEither Yes or No must be selected
27Does this Nutrition provider have an approved Congregate Nutrition Waiver for 2022?NA
28Is this Nutrition provider requesting a Congregate Nutrition Program Approval for 2023?NA
29Total number of meal preparation sites used by this provider:
30Total number of meal sites used by this provider:
31Does the provider make congregate meals available at least 5 days a week and 250 days a year?
YesArea Agency on Aging of the Alamo Area
NoArea Agency on Aging of Ark-TexRegion 1/10
Area Agency on Aging of Bexar CountyRegion 2/9
SubrecipientArea Agency on Aging of Brazos ValleyRegion 3
ContractArea Agency on Aging of the Capital AreaRegion 4
Area Agency on Aging of Central TexasRegion 5
Area Agency on Aging of the Coastal BendRegion 6
Area Agency on Aging of Concho ValleyRegion 7
Area Agency on Aging of Dallas CountyRegion 8
Area Agency on Aging of Deep East TexasRegion 11
Area Agency on Aging of East Texas
Area Agency on Aging of the Golden Crescent Region
Area Agency on Aging of Harris County
Area Agency on Aging of the Heart of Texas
Area Agency on Aging of Houston-Galveston
Area Agency on Aging of the Lower Rio Grande Valley
Area Agency on Aging of the Middle Rio Grande Area
Area Agency on Aging of North Central Texas
Area Agency on Aging of North Texas
Agency on Aging of the Panhandle Area
Area Agency on Aging of the Permian Basin
Agency on Aging of the Rio Grande Area
Area Agency on Aging of Southeast Texas
Area Agency on Aging of South Plains
Area Agency on Aging of South Texas
Area Agency on Aging of Tarrant County
Area Agency on Aging of Texoma
Area Agency on Aging of West Central Texas

Provider Total Budget by Serv

Provider Total Budget by Service
Provider Name:AAA Name:- 0
2/28/2024 10:16 AMRegion Number:- 0
Cost AreaTotal Agency BudgetHome Delivered Meal ProgramNutrition Education - AAA ClientsNutrition Education CCS Clients NACongregate Meal ProgramOther Meal Programs
(non-HHS)Agency Budget not Applicable to ProgramsParticipant AssessmentTransportationIf applicable replace with title of other agency programIf applicable replace with title of other agency programIf applicable replace with title of other agency programBalance not budgeted
Personnel
Salaries (Identified by Job Title)
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
Total Salaries- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Payroll Taxes & Benefits (Employer Paid)
Federal Insurance compensation Act (FICA)- 0
Texas Unemployment Compensation Act (TUCA)- 0
Federal Unemployment Tax Act (FUTA)- 0
Workers Compensation- 0
Health Insurance- 0
Retirement- 0
- 0
- 0
- 0
Total Payroll Taxes & Benefits (Employer Paid)- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Contract staff (Identify by Position)
- 0
- 0
- 0
- 0
Total Contract staff- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Total Personnel- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Professional Development
Conference (list Conference & Attendees)
- 0
- 0
Total Conferences- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Dues (list Organization Name)
- 0
- 0
Total Dues- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Materials (list Items)
- 0
- 0
Total Materials- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Total Professional Development- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Meals/Food
Raw Food
- 0
- 0
- 0
Total Raw Food- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Purchased Meals
Hot Prepared Meals Purchased from a Supplier or Central Kitchen- 0
Frozen Meals- 0
Chilled Meals- 0
Shelf Stable Meals- 0
Total Purchased Meals- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Freight
- 0
- 0
Total Freight- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Storage Cost (Food or Supply)
- 0
- 0
Total Storage Cost- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Consumables (identify by type)
Non-Capital Equipment (less that $5,000 per item)- 0
Paper/plastic goods (napkins, plates, utensils, etc)- 0
Meal Delivery Consumable Supplies- 0
Pots/Pans/Cooking Utensils- 0
- 0
- 0
Total Consumables- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Other (Identify Individually all items over $100.)
- 0
- 0
Total Other- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Total Meals/Food- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Equipment
Depreciation (identify item, year purchased, cost)
- 0
- 0
Total Depreciation- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Interest (Identify Item, year purchased, cost)
- 0
- 0
Total Interest- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Leasing (identify Item, year leased)
- 0
- 0
Total Leasing- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Maintenance (Identify Item, year purchased, cost)
- 0
- 0
Total Maintenance- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Total Equipment- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Occupancy/Building
Rent
- 0
- 0
Total Rent- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Utilities
- 0
- 0
Total Utilities- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Depreciation (identify item, year purchased, cost)
- 0
- 0
Total Depreciation- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Mortgage Interest
- 0
- 0
Total Mortgage Interest- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Insurance (identify type of insurance)
- 0
- 0
Total Insurance- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Security
- 0
- 0
Total Security- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Janitorial
- 0
- 0
Total Security- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Repair (Identify all items over $100.)
- 0
- 0
Total Repair- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Taxes (Identify Type of Tax)
- 0
- 0
Total Taxes- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Total Occupancy/Building- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Transportation/Travel
Mileage Reimbursement
- 0
- 0
Total Mileage Reimbursement- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Delivery
- 0
- 0
Total Delivery- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Gas & Oil
- 0
- 0
Total Gas & Oil- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Repairs (Identify Item & year purchased)
- 0
- 0
Total Repair- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Insurance (identify type of insurance)
- 0
- 0
Total Insurance- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Depreciation/Lease (identify item, year purchased, cost)
- 0
- 0
Total Depreciation- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Interest
- 0
- 0
Total Interest- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Tags & Licenses
- 0
- 0
Total Tags & Licenses- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Total Transportation/Travel- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Administrative & General
Advertising
- 0
- 0
Total Advertising- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Printing
- 0
- 0
Total Printing- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Copying
- 0
- 0
Total Copying- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Office Supplies
- 0
- 0
Total Office supplies- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Contractual Agreements
- 0
- 0
Total Contractual Agreements- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Postage
- 0
- 0
Total Postage- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Telecommunications
- 0
- 0
Total Telecommunication- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Liability Insurance
- 0
- 0
Total Liability Insurance- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Legal Fees
- 0
- 0
Total Legal Fees- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Accounting Fees
- 0
- 0
Total Accounting Fees- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Consulting Fees
- 0
- 0
Total Consulting Fees- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Other Fees (Explain)
- 0
- 0
Total Other Fees- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Audit
- 0
- 0
Total Audit- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Other Misc. (Explain)
- 0
- 0
Total other Misc.- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Total Administrative & General- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Total
Total of all Cost Areas- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
Percentage of Total Cost0.000%0.000%0.000%0.000%0.000%0.000%0.000%0.000%0.000%0.000%0.000%0.000%
Budgeted Meals
Provider Prepared Meals
Hot Meals- 0
Frozen Meals- 0
Chilled Meals- 0
Shelf Stable Meals- 0
Total Provider Prepared Meals- 0- 0- 0- 0
Purchased Meals
Hot Prepared Meals Purchased from a Supplier or Central Kitchen- 0
Frozen Meals- 0
Chilled Meals- 0
Shelf Stable Meals- 0
Total Purchased Meals- 0- 0- 0- 0
Total Budgeted Meals- 0- 0- 0- 0
% of Total Meals0%0%0%
Whole Unit Rate- 0- 0
AAA Contractors/Subrecipients may choose to provide required Nutrition Education as a separate service and exclude costs related to Nutrition Education from the meal rate.
If the cost of Nutrition Education is to be provided as a separate service, enter an N. This will
exclude Nutrition Education costs from the meal rate.
- 0
HDMERROR:#DIV/0!
CMERROR:#DIV/0!
Yes
No
NA

Provider Service Area

2/28/2024 10:16 AM
Provider Name:
AAA Name:0
Type of Provider:

Provider Service Area

This section is used to identify the nutrition provider's service area for FFY 2025. This will assist HHS in defining unserved areas of the state.

Please specify the provider's service area by geographical location (county, city, zip code, etc.) If the provider serves an entire county, record the name of the county. City, zip code, and other designations can be used when the provider agency is not serving an entire county.

Examples: 1) City of El Paso; 2) Harris County; 3) Two mile radius of the city limits of Rockdale and Cameron; 4) City of Cedar Park, Leander Zip Codes 78745 and 78746.

Congregate Meals Service Area:

Home Delivered Meals - AAA Service Area:

Analysis Tool

2/28/2024 10:16 AM
Provider Name:
AAA Name:- 0
Region Number:- 0
Section 1
This section is used to compare the amounts budgeted/allocated to each program by cost area.

Example: What percent of the agencies personnel cost is budgeted/allocated to home delivered meals versus congregate meals and other agency programs? The information should be used as a review tool to gain an understanding of the agencies overall budget and operations.

Percentage of the Total Cost Area Budgeted to:

Cost AreaHome Delivered MealsCongregate MealsOther Programs
Total Personnel0.00%0.00%0.00%
Total Professional Development0.00%0.00%0.00%
Total Raw Food0.00%0.00%0.00%
Total Purchased Meals0.00%0.00%0.00%
Total Freight0.00%0.00%0.00%
Total Storage Cost0.00%0.00%0.00%
Total Consumables0.00%0.00%0.00%
Total Other Meal/Food0.00%0.00%0.00%
Total Meals/Food0.00%0.00%0.00%
Total Equipment0.00%0.00%0.00%
Total Occupancy/Building0.00%0.00%0.00%
Total Transportation/Travel0.00%0.00%0.00%
Total Administrative & General0.00%0.00%0.00%
Total of all Cost Areas0.00%0.00%0.00%
Example of how to use this information:
Compare the percentage of total personnel budgeted to the meal programs and other programs. Based on the percentages of total cost does the percentages appear reasonable and equitably distributed between programs? If the percentages are not easily identified as equitable a further review of the salaries may be necessary. There are many reasons for variances in percentage for example the agency may use volunteers for some of the programs this may cause the overall percentages appear out of line.

REMEMBER: There are no right or wrong percentages. The reviewer through analysis of the budget and discussions with the provider must determine if the allocation is acceptable.

The reviewers notes detailing budget review, discussions with the provider, and decisions made should be included in the work file.

Section 2
This section is a summary of information to use to analyze the cost and how they are allocated between Congregate and Home Delivered Meals. The information is presented in three different ways:

� Total Cost: Amount budgeted by cost area � Percentage of total cost: Percentage of the total of cost area for the two meal programs applied to each program � Cost per unit: How much of the unit cost is used to pay for each cost area. $X.XX of the cost of each meal is for XX cost area.

Below the cost area summary information is additional information showing:

� Percentage of the total budgeted meal cost applied to the home delivered and congregate meal programs � Percentage of the total budgeted meals (home delivered & congregate) applied to the home delivered and congregate programs.

� Whole Unit rate for each meal program � Calculated meal rate based on information entered on the home delivered and congregate meal budget worksheets.

Total Cost Percentage of Total Cost Cost per unit

Cost AreaHome Delivered MealsCongregate MealsHome Delivered MealsCongregate MealsHome Delivered MealsCongregate Meals
Total Personnel- 0- 00.00%0.00%- 0- 0
Total Professional Development- 0- 00.00%0.00%- 0- 0
Total Raw Food- 0- 00.00%0.00%- 0- 00
Purchased Meals
Hot Prepared Meals Purchased from a Supplier or Central Kitchen- 0- 00.00%0.00%- 0- 0
Frozen Meals- 0- 00.00%0.00%- 0- 0
Chilled Meals- 0- 00.00%0.00%- 0- 0
Shelf Stable Meals- 0- 00.00%0.00%- 0- 0
Total Consumables- 0- 00.00%0.00%- 0- 0
Total Other Meal/Food- 0- 00.00%0.00%- 0- 0
Total Meals/Food- 0- 00.00%0.00%- 0- 0
Total Equipment- 0- 00.00%0.00%- 0- 0
Total Occupancy/Building- 0- 00.00%0.00%- 0- 0
Total Transportation/Travel- 0- 00.00%0.00%- 0- 0
Total Administrative & General- 0- 00.00%0.00%- 0- 0
Subtotal- 0- 00.00%0.00%- 0- 0
Nutrition EducationERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!
TotalERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!
Total Budgeted Cost0.000.000.00
Percentage of Total Budgeted Meal CostERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!
Total Budgeted Meals000
Percentage of Total Budgeted MealsERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!

Whole Unit Rate (Full Cost per Meal) ERROR:#DIV/0! ERROR:#DIV/0!

Calculated Rate - 0 - 0

Example of how to use this information:
Review each of the cost areas based on the three different ways the information is presented. Determine if the dollar amount is reasonable for each of the cost areas. Is the percentage of the cost allocation between congregate and home delivered comparable to the percentage of total budgeted meals for each program?

Review examples:

� Occupancy/Building cost is expected to be higher for congregate than home delivered because the home delivered program should only be charged a share of the cost for the kitchen and delivery preparation area for the time those areas are used to prepare and disburse meals. The congregate program would be charged a share of the cost for the kitchen area for the time those areas are used to prepare meals and include the cost associated with the area used to consume meals.

� How are Personnel costs allocated between the two meal programs? Is the allocation based on the percentage of meals, percentage of total cost, or actual time spent between the two programs?

� Review the cost per unit of raw food. Is the amount the same for both programs? If not, why are they different?

� Review the total cost per unit rates, are the rates for the programs similar? Because the program requirements are different, small variances are expected. If the variances cannot be explained by program differences, you need to explain in your review papers why they are different.

Home Delivered Meal Budget

Home Delivered Meal Budget Worksheet
Provider Name:- 0Review of Most Recent Completed Year Approved Budget to Actual Year End Expense and Current Proposed Budget
AAA Name:- 0
Region Number:- 0
2/28/24 10:16 AM2/28/24 10:16 AM2/28/24 10:16 AM2/28/24 10:16 AM2/28/24 10:16 AM
Most Recent Completed Budget Year2023Proposed BudgetExplanation of Variances

Expense per General Ledger Approved Budget Variance Budget minus Expenses Percentage of Variance Percentage of Unit Cost Proposed Budget Percentage Variance Prior Year Actual to Proposed Budget Percentage of Unit Cost Inflation Factor 2023 to 2024 2.700% Stoglin,Marx (HHSC): Stoglin,Marx (HHSC):

Check Inflation factor

Inflation Factor 2024 to 20252.400%
Combined Inflation Factor5.100%
1. An explanation of variance must be provided for each cost area where the expenses per General Ledger varies from the approved budget for the most recent completed year by 10% or more; and

2. An explanation of variance must be provided for each cost area where the proposed budget amount exceeds the prior year actual amount by more than the two year combined inflation factor.

Personnel
Salaries, PR Taxes & Benefits00.00%0.000.00%
Contract staff, Compensation00.00%0.000.00%
Total- 00.0000.00%0.00%0.000.00%ERROR:#DIV/0!
Nutrition Education
Salaries, PR Taxes & Benefits00.00%ERROR:#DIV/0!ERROR:#DIV/0!
Contract staff, Compensation00.00%ERROR:#DIV/0!ERROR:#DIV/0!
Materials00.00%ERROR:#DIV/0!ERROR:#DIV/0!
Conference00.00%ERROR:#DIV/0!ERROR:#DIV/0!
Total- 00.0000.00%0.00%ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!
Professional Development
Conference00.00%0.000.00%
Dues00.00%0.000.00%
Materials00.00%0.000.00%
Total- 00.0000.00%0.00%0.000.00%ERROR:#DIV/0!
Meals/Food
Raw Food00.00%0.000.00%
Purchased Meals00.00%0.000.00%
Freight00.00%0.000.00%
Storage00.00%0.000.00%
Consumables00.00%0.000.00%
Other00.00%0.000.00%
Total- 00.0000.00%0.00%0.000.00%ERROR:#DIV/0!
Equipment
Depreciation00.00%0.000.00%
Interest00.00%0.000.00%
Leasing00.00%0.000.00%
Maintenance00.00%0.000.00%
Total- 00.0000.00%0.00%0.000.00%ERROR:#DIV/0!
Occupancy/Building
Rent00.00%0.000.00%
Utilities00.00%0.000.00%
Depreciation00.00%0.000.00%
Mortgage Interest00.00%0.000.00%
Insurance00.00%0.000.00%
Security00.00%0.000.00%
Janitorial00.00%0.000.00%
Repair00.00%0.000.00%
Taxes00.00%0.000.00%
Total- 00.0000.00%0.00%0.000.00%ERROR:#DIV/0!
Transportation/Travel
Mileage Reimbursement00.00%0.000.00%
Delivery00.00%0.000.00%
Gas & Oil00.00%0.000.00%
Repairs00.00%0.000.00%
Insurance00.00%0.000.00%
Depreciation/Lease00.00%0.000.00%
Interest00.00%0.000.00%
Tags & Licenses00.00%0.000.00%
Total- 00.0000.00%0.00%0.000.00%ERROR:#DIV/0!
Administrative & General
Advertising00.00%0.000.00%
Printing00.00%0.000.00%
Copying00.00%0.000.00%
Office Supplies00.00%0.000.00%
Contractual Agreements00.00%0.000.00%
Postage00.00%0.000.00%
Telecommunications00.00%0.000.00%
Liability Insurance00.00%0.000.00%
Legal Fees00.00%0.000.00%
Accounting Fees00.00%0.000.00%
Consulting Fees00.00%0.000.00%
Other Fees (Explain)00.00%0.000.00%
Audit00.00%0.000.00%
Other Misc. (Explain)00.00%0.000.00%
Total- 00.0000.00%0.00%0.000.00%ERROR:#DIV/0!
Total
Total of all Cost Areas0.000.000.000.00%0.00%ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!
Total Number of Meals
Whole Cost per Meal0.000.00
Approved Meal Rate (Title III & Title XX)- 0
Approved Meal Rate (Title XIX)- 0
Funding SourceProposed MealsCalculated RateRevenue
HHS - OAAA0.00- 0Proposed Meals * Calculated Units
HHS - Title XX0.00- 0Proposed Meals * Calculated Units
DADS - Title XIX (CBA)0.00- 0Proposed Meals * Calculated Units
DADS - Title XIXProposed Meals * Calculated Units
Program Income0.00- 0Proposed Meals * Calculated Units
Other Funds - Eligible Meals0.00- 0Proposed Meals * Calculated Units
Other Funds - Non-Eligible Meals0.00- 0Proposed Meals * Calculated Units
Local Funds - Required MatchNA0.00- 0HHS OAAA Proposed Meals +Title XX Proposed Meals *Calculated Rate
Local Funds - Cap Limit Exceeded HHS OAAA & Title XXNA0.00- 0HHS OAAA Proposed Meals +Title XX Proposed Meals *Calculated Rate
Local Funds - Cap Limit Exceeded Title XIXNA0.00- 0HHS Title XIX Proposed Meals *Calculated Rate
Total Meals by Funding Source- 0- 0
Provider Total Budgeted Home Delivered Meals- 0
Variance (Provider Total Budgeted Home Delivered Meals - Total Meals by Funding Source)- 0
Estimated Number of Nutrition Education Units AAA Clients
Nutrition Education Budget - AAA ClientsERROR:#DIV/0!
Calculated Cost per Unit- 0

Certification HDM

2/28/24 10:16 AM
Provider Name:- 0
AAA Name:- 0
Region Number:- 0
Home Delivered Meals
BUDGET WORKSHEET CERTIFICATION

AS SIGNER OF THIS BUDGET WORKSHEET, I HEREBY CERTIFY THAT:

· I have read the note below and the instructions applicable to this budget worksheet.

· I have reviewed this budget worksheet after its preparation.

·To the best of my knowledge and belief, this budget worksheet is true, correct and
complete, and was prepared in accordance with the instructions applicable to this
budget worksheet.
·This budget worksheet was prepared from the books and records of the contracted
provider.
·I acknowledge that all books and records related to this rate setting process are
subject to audit in accordance with contract requirements and all applicable federal
and state laws.
Note:The person legally responsible for the conduct of the contracted provider must
sign this Budget Worksheet Certification. If a sole proprietor, the owner
must sign the Budget Worksheet Certification. If a partnership, a partner must
sign the Budget Worksheet Certification. If a corporation, the person authorized by the
Board of Directors Resolution must sign the Budget Worksheet Certification.
Misrepresentation of information contained in the budget worksheet may result in
adverse action, up to and including contract termination. Furthermore, falsification of
information in the budget worksheet may result in a referral for prosecution.
0
Name of Contracted ProviderPrinted/Typed Name of Signer

Date Signature

Signer Authority:Sole ProprietorAssociation Officer
(check one)PartnerBoard Member
Corporate OfficerGovernmental Official

Unit Rate Calculation HDM

2/28/24 10:16 AM
Provider Name:- 0
AAA Name:- 0
Region Number:- 0
Home Delivered Meals
BUDGET WORKSHEET CALCULATION OF THE PER MEAL UNIT RATE

1. Total Budgeted Expenses for Contract Year 1. ERROR:#DIV/0!

2. Total Number of Anticipated Meals to be Provided by Funding Source

HHS OAAA 0 Title XX 0 Title XIX 0

Program Income0Other Funds Eligible Meals0Other Funds -
Non-Eligible Meals02.- 0

3. Whole Unit Rate (Line 1 divided by Line 2) 3. $ - 0

Reimbursement Calculation
HHS OAAA & Title XXTitle XIX
4. Projected NSIP per Meal Value0.73N/A

5. Rate Less NSIP per Meal Value $ - 0 N/A

6. Mandatory Local Match of 10%$ - 0
** If Applicable, Match Reduction

From the In-kind Match

Certification form$ - 0
Required Cash Match$ - 0N/A
7. Proposed Meal Rate (Line 3 minus Line 6)$ - 0$ - 0
As of May 26, 2023, Common Provider Unit Rate cannot exceed 6.46
8. Rate Cap Applicable to Title XIX, Title XX
and HHS OAAA Common Providers$ 6.46

9. Excess of Cap Rate Reduction $ - 0 $ - 0

Accepted Unit Rate for Current Year $ - 0 NA

** If any portion of the required match is in-kind, you must complete an In-Kind Match Certification form.
By signing below, the provider acknowledges that all related records are subject to audit in accordance with contract
requirements and all applicable federal and state laws.
0
Legal Name of Contracted ProviderPrinted/Typed Name of Signer
SignatureDate
00
Name of Area Agency on AgingHealth and Human Services
0NA
Printed/Typed Name of SignerPrinted/Typed Name of Signer

Signature Signature

DateDate
Calculation of In-Kind Value
1. Required Match Rate- 0
2. TDoA units + DHS units- 0
3. Required Match Rate (1) Multiplied by the anticipated number of TDoA units (2)- 0
4. Total Valuation from the In-Kind Certification- 0
5. Balance of Required Match (3-4)- 0
6. TDoA units + DHS units- 0
7. Balance of Required Match (5) Divided by TDoA units (6)- 0
8. Required Match Rate- 0
9. Reduced Required Match If (8) is equal to or less than 0 this will equal (8) or else (8-7)- 0
0

In-Kind Certification HDM

2/28/24 10:16 AM2/28/24 10:16 AM
AAA Name:- 0
Region Number:- 0
Home Delivered Meals
IN-KIND MATCH CERTIFICATION
Provider:
In-kind Contribution(s):$0
For any item identified below, the provider must maintain monthly supporting documentation.

ITEM DATE OF RECEIPT VALUE

TOTAL $0

Note: All contributions must meet the requirements of IRS Publication 561 http://www.irs.gov/pub/irs-pdf/p561.pdf

Examples of Documentation Include:
Rent:1.Letter of Agreement with Owner
2.Adequate Valuation of Property on a Current Basis (this should be reviewed at least every two years and if senior center, based on property value and center participation)
Labor:1.Minimum wage
2.Documented prevailing wage in the Area. For prevailing wage information visit the Texas Workforce Commission’s website at https://efte.twc.texas.gov/prevailing_wage_issues.html
All in-kind labor must be required for the service to be provided. If you would not hire someone to perform the labor if it
were not in-kind then you cannot count it.
Utilities:1.Copy of Bill
2.Agreement of Amount Paid if Partial

Name of Contracted Provider Printed/Typed Name of Signer

Date Signature

Budget Worksheet FFY 2005 In-Kind Certification http://www.irs.gov/pub/irs-pdf/p561.pdfhttps://efte.twc.texas.gov/prevailing_wage_issues.html Congregate Meal Budget

Congregate Meal Budget Worksheet
Provider Name:- 0Review of Most Recent Completed Year Approved Budget to Actual Year End Expense and Current Proposed Budget
AAA Name:- 0
2/28/24 10:16 AM
Most Recent Completed Budget Year2023Proposed BudgetExplanation of Variances

Cost Area Expense per General Ledger Approved Budget Variance Budget minus

ExpensesPercentage of VariancePercentage of Unit CostProposed BudgetPercentage Variance - Prior Year Actual to Proposed BudgetPercentage of Unit CostInflation Factor 2023 to 20242.700%
Inflation Factor 2024 to 20252.400%
Combined Inflation Factor5.100%
1. An explanation of variance must be provided for each cost area where the expenses per General Ledger varies from the approved budget for the most recent completed year by 10% or more; and

2. An explanation of variance must be provided for each cost area where the proposed budget amount exceeds the prior year actual amount by more than the two year combined inflation factor.

Personnel
Salaries, PR Taxes & Benefits00.00%- 00.00%
Contract staff, Compensation00.00%- 00.00%- 0
Total- 00.0000.00%0.00%- 00.00%ERROR:#DIV/0!- 0
Nutrition Education
Salaries, PR Taxes & Benefits00.00%ERROR:#DIV/0!ERROR:#DIV/0!
Contract staff, Compensation00.00%ERROR:#DIV/0!ERROR:#DIV/0!
Materials00.00%ERROR:#DIV/0!ERROR:#DIV/0!
Conference00.00%ERROR:#DIV/0!ERROR:#DIV/0!- 0
Total- 00.0000.00%0.00%ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!
Professional Development
Conference00.00%- 00.00%
Dues00.00%- 00.00%- 0
Materials00.00%- 00.00%- 0
Total- 00.0000.00%0.00%- 00.00%ERROR:#DIV/0!- 0
Meals/Food
Raw Food00.00%- 00.00%
Purchased Meals00.00%- 00.00%- 0
Freight00.00%- 00.00%- 0
Storage00.00%- 00.00%- 0
Consumables00.00%- 00.00%- 0
Other00.00%- 00.00%- 0
Total- 00.0000.00%0.00%- 00.00%ERROR:#DIV/0!- 0
Equipment
Depreciation00.00%- 00.00%
Interest00.00%- 00.00%- 0
Leasing00.00%- 00.00%- 0
Maintenance00.00%- 00.00%- 0
Total- 00.0000.00%0.00%- 00.00%ERROR:#DIV/0!- 0
Occupancy/Building
Rent00.00%- 00.00%
Utilities00.00%- 00.00%- 0
Depreciation00.00%- 00.00%- 0
Mortgage Interest00.00%- 00.00%- 0
Insurance00.00%- 00.00%- 0
Security00.00%- 00.00%- 0
Janitorial00.00%- 00.00%- 0
Repair00.00%- 00.00%- 0
Taxes00.00%- 00.00%- 0
Total- 00.0000.00%0.00%- 00.00%ERROR:#DIV/0!- 0
Transportation/Travel
Mileage Reimbursement00.00%- 00.00%
Delivery00.00%- 00.00%- 0
Gas & Oil00.00%- 00.00%- 0
Repairs00.00%- 00.00%- 0
Insurance00.00%- 00.00%- 0
Depreciation/Lease00.00%- 00.00%- 0
Interest00.00%- 00.00%- 0
Tags & Licenses00.00%- 00.00%- 0
Total- 00.0000.00%0.00%- 00.00%ERROR:#DIV/0!- 0
Administrative & General
Advertising00.00%- 00.00%
Printing00.00%- 00.00%- 0
Copying00.00%- 00.00%- 0
Office Supplies00.00%- 00.00%- 0
Contractual Agreements00.00%- 00.00%- 0
Postage00.00%- 00.00%- 0
Telecommunications00.00%- 00.00%- 0
Liability Insurance00.00%- 00.00%- 0
Legal Fees00.00%- 00.00%- 0
Accounting Fees00.00%- 00.00%- 0
Consulting Fees00.00%- 00.00%- 0
Other Fees (Explain)00.00%- 00.00%- 0
Audit00.00%- 00.00%- 0
Other Misc. (Explain)00.00%- 00.00%- 0
Total- 00.0000.00%0.00%- 00.00%ERROR:#DIV/0!- 0
Total
Total of all Cost Areas0.000.000.000.00%0.00%ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!
Total Number of Meals
Whole Cost per Meal0.000.00
Approved Meal Rate Title III- 0
Funding SourceProposed MealsCalculated RateRevenue
HHS OAAA - Match Required0.000.00Proposed Meals * Calculated Units
Program Income0.000.00Proposed Meals * Calculated Units
Other Funds - Eligible Meals0.000.00Proposed Meals * Calculated Units
Other Funds - Non-Eligible Meals0.000.00Proposed Meals * Calculated Units
Local Funds - Required MatchNA0.000.00Proposed Meals * Calculated Units
Other Sources 50.000.00Proposed Meals * Calculated Units
Other Sources 60.000.00Proposed Meals * Calculated Units
Total Meals by Funding Source00.00Total Revenue
Provider Total Budgeted Congregate Meals0
Variance (Provider Total Budgeted Congregate Meals -
Total Meals by Funding Source)0
Estimated Number of Nutrition Education Units AAA Clients
Nutrition Education Budget - AAA ClientsERROR:#DIV/0!
Calculated Cost per Unit- 0

Unit Rate Calculation CM

2/28/24 10:16 AM
Provider Name:- 0
AAA Name:- 0
Congregate Meals
BUDGET WORKSHEET CALCULATION OF THE PER MEAL UNIT RATE

1. Total Budgeted Expenses for Contract Year 1. ERROR:#DIV/0!

2. Total Number of Anticipated Meals to be Provided by Funding Source

HHS OAAA 0 Other Funds Eligible Meals 0 Other Sources 5 0

Program Income 0 Other Funds - Non-Eligible Meals 0 Other Sources 6 0 2. - 0

3. Whole Unit Rate (Line 1 divided by Line 2) 3. $ - 0

Reimbursement Calculation
HHS OAAA
4. Projected NSIP per Meal Value0.73

5. Rate Less NSIP per Meal Value $ - 0

6. Mandatory Local Match of 10%$ - 0
** If Applicable, Match Reduction

From the In-kind Match

Certification form$ - 0
Required Cash Match$ - 0
7. Proposed Meal Rate (Line 3 minus Line 6)$ - 0
** If any portion of the required match is in-kind, you must complete an In-Kind Match Certification form.
By signing below, the provider acknowledges that all related records are subject to audit in accordance with
contract requirements and all applicable federal and state laws.
0
Legal Name of Contracted ProviderPrinted/Typed Name of Signer
SignatureDate
0
Name of Area Agency on Aging
0
Printed/Typed Name of Signer

Signature

Date
Calculation of In-Kind Value
1. Required Match Rate- 0
2. TDoA units + DHS units- 0
3. Required Match Rate (1) Multiplied by the anticipated number of TDoA units (2)- 0
4. Total Valuation from the In-Kind Certification- 0
5. Balance of Required Match (3-4)- 0
6. TDoA units + DHS units- 0
7. Balance of Required Match (5) Divided by TDoA units (6)- 0
8. Required Match Rate- 0
9. Reduced Required Match If (8) is equal to or less than 0 this will equal (8) or else (8-7)- 0

Certification CM

2/28/24 10:16 AM
Provider Name:- 0
AAA Name:- 0
Congregate Meals
BUDGET WORKSHEET CERTIFICATION

AS SIGNER OF THIS BUDGET WORKSHEET, I HEREBY CERTIFY THAT:

· I have read the note below and the instructions applicable to this budget worksheet.

· I have reviewed this budget worksheet after its preparation.

·To the best of my knowledge and belief, this budget worksheet is true, correct and
complete, and was prepared in accordance with the instructions applicable to this
budget worksheet.
·This budget worksheet was prepared from the books and records of the contracted
provider.
·I acknowledge that all books and records related to this rate setting process are
subject to audit in accordance with contract requirements and all applicable federal
and state laws.
Note:The person legally responsible for the conduct of the contracted provider must
sign this Budget Worksheet Certification. If a sole proprietor, the owner
must sign the Budget Worksheet Certification. If a partnership, a partner must
sign the Budget Worksheet Certification. If a corporation, the person authorized by the
Board of Directors Resolution must sign the Budget Worksheet Certification.
Misrepresentation of information contained in the budget worksheet may result in
adverse action, up to and including contract termination. Furthermore, falsification of
information in the budget worksheet may result in a referral for prosecution.
0
Name of Contracted ProviderPrinted/Typed Name of Signer

Date Signature

Signer Authority:Sole ProprietorAssociation Officer
(check one)PartnerBoard Member
Corporate OfficerGovernmental Official

In-Kind Certification CM

2/28/24 10:16 AM
AAA Name:- 0
Congregate Meals
IN-KIND MATCH CERTIFICATION
Provider:
In-kind Contribution(s):$0
For any item identified below, the provider must maintain monthly supporting documentation.

ITEM DATE OF RECEIPT VALUE

TOTAL $0

Note: All contributions must meet the requirements of IRS Publication 561 http://www.irs.gov/pub/irs-pdf/p561.pdf

Examples of Documentation Include:
Rent:1.Letter of Agreement with Owner
2.Adequate Valuation of Property on a Current Basis (this should be reviewed at least every two years and if senior center, based on property value and center participation)
Labor:1.Minimum wage
2.Documented prevailing wage in the Area. For prevailing wage information visit the Texas Workforce Commission’s website at https://efte.twc.texas.gov/prevailing_wage_issues.html
All in-kind labor must be required for the service to be provided. If you would not hire someone to perform the labor if it
were not in-kind then you cannot count it.
Utilities:1.Copy of Bill
2.Agreement of Amount Paid if Partial
0
Name of Contracted ProviderPrinted/Typed Name of Signer

Date Signature

Participant Assessment Budget

Participant Assessment
Provider Name:- 0Review of Most Recent Completed Year Approved Budget to Actual Year End Expense and Current Proposed Budget
AAA Name:- 0
2/28/24 10:16 AM
Most Recent Completed Budget Year2023Proposed BudgetExplanation of Variances

Cost Area Expense per General Ledger Approved Budget Variance minus

ExpensesPercentage of VariancePercentage of Unit CostProposed BudgetPercentage Variance - Prior Year Actual to Proposed BudgetPercentage of Unit CostInflation Factor 2023 to 20242.700%
Inflation Factor 2024 to 20252.400%
Combined Inflation Factor5.100%
1. An explanation of variance must be provided for each cost area where the expenses per General Ledger varies from the approved budget for the most recent completed year by 10% or more; and

2. An explanation of variance must be provided for each cost area where the proposed budget amount exceeds the prior year actual amount by more than the two year combined inflation factor.

Personnel
Salaries, PR Taxes & Benefits00.00%0.000.00%
Contract staff, Compensation00.00%0.000.00%
Total- 00.0000.00%0%0.000.00%0%
Nutrition Education
Salaries, PR Taxes & Benefits00.00%
Contract staff, Compensation00.00%
Materials00.00%
Conference00.00%
Total- 00.0000.00%0%0.000%
Professional Development
Conference00.00%0.000.00%
Dues00.00%0.000.00%
Materials00.00%0.000.00%
Total- 00.0000.00%0%0.000.00%0%
Meals/Food
Raw Food00.00%0.000.00%
Purchased Meals00.00%0.000.00%
Freight00.00%0.000.00%
Storage00.00%0.000.00%
Consumables00.00%0.000.00%
Other00.00%0.000.00%
Total- 00.0000.00%0%0.000.00%0%
Equipment
Depreciation00.00%0.000.00%
Interest00.00%0.000.00%
Leasing00.00%0.000.00%
Maintenance00.00%0.000.00%
Total- 00.0000.00%0%0.000.00%0%
Occupancy/Building
Rent00.00%0.000.00%
Utilities00.00%0.000.00%
Depreciation00.00%0.000.00%
Mortgage Interest00.00%0.000.00%
Insurance00.00%0.000.00%
Security00.00%0.000.00%
Janitorial00.00%0.000.00%
Repair00.00%0.000.00%
Taxes00.00%0.000.00%
Total- 00.0000.00%0%0.000.00%0%
Transportation/Travel
Mileage Reimbursement00.00%0.000.00%
Delivery00.00%0.000.00%
Gas & Oil00.00%0.000.00%
Repairs00.00%0.000.00%
Insurance00.00%0.000.00%
Depreciation/Lease00.00%0.000.00%
Interest00.00%0.000.00%
Tags & Licenses00.00%0.000.00%
Total- 00.0000.00%0%0.000.00%0%
Administrative & General
Advertising00.00%0.000.00%
Printing00.00%0.000.00%
Copying00.00%0.000.00%
Office Supplies00.00%0.000.00%
Contractual Agreements00.00%0.000.00%
Postage00.00%0.000.00%
Telecommunications00.00%0.000.00%
Liability Insurance00.00%0.000.00%
Legal Fees00.00%0.000.00%
Accounting Fees00.00%0.000.00%
Consulting Fees00.00%0.000.00%
Other Fees (Explain)00.00%0.000.00%
Audit00.00%0.000.00%
Other Misc. (Explain)00.00%0.000.00%
Total- 00.0000.00%0%0.000.00%0%
Total
Total of all Cost Areas0.000.00- 00.00%- 0- 00.00%0%
Total Number Units- 00.00%
Whole Cost per Unit0.000.00- 00.00%Budgeted UnitsBudgeted Cost per Unit
Approved Unit Rate- 0
Funding SourceProposed UnitsCalculated RateRevenue
HHS OAAA - 10 % Match Required- 0- 0
HHS OAAA - 25 % Match Required- 0- 0
HHS OAAA - Full Unit Rate- 0- 0
Program Income- 0- 0
Local Funds- 0- 0
Other Funds- 0- 0
Local Funds - Required Match 10%NA- 0- 0
Local Funds - Required Match 25%NA- 0- 0
Other Sources 6- 0- 0
Other Sources 7- 0- 0
Other Sources 8- 0- 0
Total Units by Funding Source- 0- 0

Total Revenue

Unit Rate Calculation PA

2/28/24 10:16 AM
Provider Name:- 0
AAA Name:- 0
Participant Assessment
BUDGET WORKSHEET CALCULATION OF THE UNIT RATE

1.Total Budgeted Expenses for Contract Year 1. $ - 0

2.Total Number of Anticipated Units to be Provided
HHS OAAA - 10 % Match Required0Program Income0Other Sources 60
HHS OAAA - 25 % Match Required0Local Funds0Other Sources 70
HHS OAAA - Full Unit Rate0Other Funds0Other Sources 802.- 0

3. Cost per unit (Line 1 divided by Line 2) - Full Unit Rate 3. $ - 0

Reimbursement Calculation for Contracts Requiring Unit Rate Match Reduction

4. Mandatory Local Match of10%$ - 0
** If Applicable, Match Reduction From the In-kind Match Certification form$ - 0
Required Match4.$ - 0
5.Full Unit Rate Less Required Match (Line 3 minus Line 4)5.$ - 0
4. Mandatory Local Match of25%$ - 0
** If Applicable, Match Reduction From the In-kind Match Certification form$ - 0
Required Match4.$ - 0
5.Full Unit Rate Less Required Match (Line 3 minus Line 4)5.$ - 0

**If any portion of the required match is in-kind, you must complete an In-Kind Match Certification form.

Contract Reimbursed at Full Cost Per Unit Rate. Match Requirements Will Be Met Through Provision of Additional Units

$ - 0
Contractor InitialAAA Initial

Legal Name of Contracted Provider Name of Area Agency on Aging

SignatureSignature
00
Printed/Typed Name of SignerPrinted/Typed Name of Signer
DateDate
Calculation of In-Kind Value
1. Required Match Rate- 0
2. TDoA units- 0
3. Required Match Rate (1) Multiplied by the anticipated number of TDoA units (2)- 0
4. Total Valuation from the In-Kind Certification- 0
5. Balance of Required Match (3-4)- 0
6. TDoA units + DHS units- 0
7. Balance of Required Match (5) Divided by TDoA units (6)- 0
8. Required Match Rate- 0
9. Reduced Required Match If (8) is equal to or less than 0 this will equal (8) or else (8-7)- 0

Certification PA

2/28/24 10:16 AM
Provider Name:- 0
AAA Name:- 0
Participant Assessment
BUDGET WORKSHEET CERTIFICATION

AS SIGNER OF THIS BUDGET WORKSHEET, I HEREBY CERTIFY THAT:

· I have read the note below and the instructions applicable to this budget worksheet.

· I have reviewed this budget worksheet after its preparation.

·To the best of my knowledge and belief, this budget worksheet is true, correct and
complete, and was prepared in accordance with the instructions applicable to this
budget worksheet.
·This budget worksheet was prepared from the books and records of the contracted
provider.
·I acknowledge that all books and records related to this rate setting process are
subject to audit in accordance with contract requirements and all applicable federal
and state laws.
Note:The person legally responsible for the conduct of the contracted provider must
sign this Budget Worksheet Certification. If a sole proprietor, the owner
must sign the Budget Worksheet Certification. If a partnership, a partner must
sign the Budget Worksheet Certification. If a corporation, the person authorized by the
Board of Directors Resolution must sign the Budget Worksheet Certification.
Misrepresentation of information contained in the budget worksheet may result in
adverse action, up to and including contract termination. Furthermore, falsification of
information in the budget worksheet may result in a referral for prosecution.
00
Name of Contracted ProviderPrinted/Typed Name of Signer

Date Signature

Signer Authority:Sole ProprietorAssociation Officer
(check one)PartnerBoard Member
Corporate OfficerGovernmental Official

In-Kind Certification PA

2/28/24 10:16 AM
AAA Name:- 0
Participant Assessment
IN-KIND MATCH CERTIFICATION
Provider:
In-kind Contribution(s):$0
For any item identified below, the provider must maintain monthly supporting documentation.

ITEM DATE OF RECEIPT VALUE

TOTAL $0

Note: All contributions must meet the requirements of IRS Publication 561 http://www.irs.gov/pub/irs-pdf/p561.pdf

Examples of Documentation Include:
Rent:1.Letter of Agreement with Owner
2.Adequate Valuation of Property on a Current Basis (this should be reviewed at least every two years and if senior center, based on property value and center participation)
Labor:1.Minimum wage
2.Documented prevailing wage in the Area. For prevailing wage information visit the Texas Workforce Commission’s website at https://efte.twc.texas.gov/prevailing_wage_issues.html
All in-kind labor must be required for the service to be provided. If you would not hire someone to perform the labor if it
were not in-kind then you cannot count it.
Utilities:1.Copy of Bill
2.Agreement of Amount Paid if Partial
00
Name of Contracted ProviderPrinted/Typed Name of Signer

Date Signature

Transportation Budget

Transportation
Provider Name:- 0Review of Most Recent Completed Year Approved Budget to Actual Year End Expense and Current Proposed Budget
AAA Name:- 0
2/28/24 10:16 AM
Most Recent Completed Budget Year2023Proposed BudgetExplanation of Variances

Cost Area Expense per General Ledger Approved Budget Variance minus

ExpensesPercentage of VariancePercentage of Unit CostProposed BudgetPercentage Variance - Prior Year Actual to Proposed BudgetPercentage of Unit CostInflation Factor 2023 to 20242.700%
Inflation Factor 2024 to 20252.400%
Combined Inflation Factor5.100%
1. An explanation of variance must be provided for each cost area where the expenses per General Ledger varies from the approved budget for the most recent completed year by 10% or more; and

2. An explanation of variance must be provided for each cost area where the proposed budget amount exceeds the prior year actual amount by more than the two year combined inflation factor.

Personnel
Salaries, PR Taxes & Benefits- 00.00%0.000.00%
Contract staff, Compensation- 00.00%0.000.00%
Total- 00.00- 00.00%0%0.000.00%0%
Nutrition Education
Salaries, PR Taxes & Benefits- 00.00%
Contract staff, Compensation- 00.00%
Materials- 00.00%
Conference- 00.00%
Total- 00.00- 00.00%0%0.000%
Professional Development
Conference- 00.00%0.000.00%
Dues- 00.00%0.000.00%
Materials- 00.00%0.000.00%
Total- 00.00- 00.00%0%0.000.00%0%
Meals/Food
Raw Food- 00.00%0.000.00%
Purchased Meals- 00.00%0.000.00%
Freight- 00.00%0.000.00%
Storage- 00.00%0.000.00%
Consumables- 00.00%0.000.00%
Other- 00.00%0.000.00%
Total- 00.00- 00.00%0%0.000.00%0%
Equipment
Depreciation- 00.00%0.000.00%
Interest- 00.00%0.000.00%
Leasing- 00.00%0.000.00%
Maintenance- 00.00%0.000.00%
Total- 00.00- 00.00%0%0.000.00%0%
Occupancy/Building
Rent- 00.00%0.000.00%
Utilities- 00.00%0.000.00%
Depreciation- 00.00%0.000.00%
Mortgage Interest- 00.00%0.000.00%
Insurance- 00.00%0.000.00%
Security- 00.00%0.000.00%
Janitorial- 00.00%0.000.00%
Repair- 00.00%0.000.00%

This is the start of the file's text. The full file is on GovTribe.

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