ESBD_564510_1791401344683_Exhibit_F_Inventory Rpt.xls

XLS spreadsheet 129 KB Posted

Attached to
Mortality Resources and Services
Solicitation number
HHS0017352v3
Issued by
Texas

About this file

This document is a Contractor's Property Inventory Report (Form GC-11) instruction guide and example prepared by the Texas Department of State Health Services (DSHS) for contractors managing state and local contract opportunities related to mortality resources and services. The report serves as an annual cumulative inventory submission documenting all property acquired with DSHS contract funds, with completion required by October 15 each year for the period ending August 31. Contractors must report equipment (tangible personal property with useful lifetime exceeding one year and per-unit acquisition cost exceeding $5,000 or the contractor's capitalization threshold), real property (land and permanent fixtures), controlled assets (certain property costing $500-$5,000 including computers and emergency management equipment), and other intangible property (non-copyrightable property such as domain names, URLs, or software licenses valued at $500 or more). The example inventory provided lists mortuary equipment and services assets including embalming machines (quantity 3), body movers (quantity 3 each of two types), folding prep tables (quantity 2), mortuary cots (quantity 3), tents (quantity 3), morgue trays (quantity 60), state morgue trailers (quantity 4), and commercial mobile diesel electrical generators (quantity 3), all acquired between 2008 and 2016 and located at a Royse City, Texas storage facility.

Contractors must complete the report through a standardized form with detailed columns for item description, serial numbers, unit costs rounded to the nearest dollar, acquisition dates, percentage of DSHS funding, useful life in years, program attachment numbers, DSHS program designations, physical locations, current status of use, disposition dates, sales prices if sold, and reasons for disposition or non-use. The document emphasizes that a blank form must be submitted if no property was acquired with DSHS funds, serving as certification of such. At contract expiration or termination, title to all equipment and supplies purchased with Department funds reverts to DSHS, which may transfer reversionary interest to the contractor at its discretion. Contractors are prohibited from using Department funds to purchase buildings or real property and must maintain insurance or other means for repairing or replacing assets, notifying the assigned contract manager within five business days of any loss, theft, damage, or destruction of insured equipment.

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Instructions

DSHS CONTRACTOR'S PROPERTY INVENTORY REPORT

GENERAL INFORMATION

Questions about completing the form can be sent to COSequip@dshs.state.tx.us or you can call

(512) 776-7484 and ask to speak with staff in the Fiscal Monitoring Unit.

The Contractor's Property Inventory Report (Form GC-11) must be submitted via mail or e-mail annually by October 15 to DSHS. One form should be submitted by your organization and it must list all property acquired with DSHS contract funds as of August 31 of the reporting year. Do not submit a seperate form for each DSHS contract awarded to your organization.Property acquisitions made with prior years' and current year DSHS contract funds must be included in the report. A blank form must be submitted to DSHS if no property was acquired with DSHS contract funds in prior or current reporting years. The blank form submission serves as a certification by your organization that no property was acquired with DSHS contract funds. Property that must be included on the annual inventory report includes:

Equipment - Equipment is defined as tangible personal property having a useful lifetime of more than one year and a per-unit acquisition cost that exceeds the lesser of the capitalization level established by Contractor for financial statement purposes, or $5,000.

Real Property - Real property is defined as land, including land improvements, structures and appurtenances thereto (i.e. permanent fixtures), but excludes movable machinery and equipment.

Other Intangible Property - Other Intangible Property is defined as non-copyrightable intangible property that was developed, produced or obtained by Contractor as a specific requirement under the Contract or under any grant that funds the Contract, such as domain names, URLs, or software licenses with a value of $500 or more.

Controlled Assets: Controlled assets are defined as tangible personal property, including firearms, regardless of the acquisition cost, and the following assets with an acquisition cost of $500 or more, but less than $5,000, which includes desktop and laptop computers, (including notebooks, tablets and similar devices), non-portable printers and copiers, emergency management equipment, communication devices and systems, medical and laboratory equipment, and media equipment.

INSTRUCTIONS FOR COMPLETING THIS FORM
Complete the general information at the top of the first tab [Page 1] of the inventory report; subsequent worksheets will be automatically populated with the general information entered on the first page. If additional space is needed to enter information within a cell, use the next row.

The report must be submitted either by e-mail or mail to DSHS. d E-mail: COSequip@dshs.state.tx.us d Mailing Address: Texas Department State Health Services Contract Oversight and Support Section Mail Code 1326 P.O. Box 149347 Austin, Texas 78714-9347 General Information:

Enter the following information on tab "Page 1(1)"; it will automatically populate to the other worksheets:

Enter the reporting period (i.e. 2009) in cell "K3".

Enter the name, vendor ID, and address of your organization.

Enter the name of the person in your organization that DSHS staff can contact if there are questions.

Enter the contact persons phone number.

Enter the date that the report was completed.

If you need to add additional worksheets:

- Click on the last worksheet tab of the workbook

- Keep the mouse cursor (pointer) on the last worksheet tab

- Hold down the "Ctrl" and "Alt" keys, left click (holding down left click) and move the cursor (pointer) to the right (of the last worksheet tab) on the tab bar

- Release the left click and copied worksheet will appear

No.
This column is pre-numbered 1-10. As you add more worksheets to the workbook you can change the numbers on the additional worksheets to correspond with the next number in the sequence of inventory items. For example, worksheet 2, if added, would start with the number 11 and end with number 20.
Item Description
Enter Item description and relevant identification information such as: manufacturer, make, model number, color, and specifications.
Serial #
Enter the manufacturer's serial number and/or an asset identification tag number if used by your organization.
Unit Cost
Enter the total unit cost of the item if equipment or controlled assets; total acquisition/development cost if real property or other intangible property (round to the nearest dollar).
Date Acquired
Enter date item was received (mm/dd/yy); or acquired in the case of real property; or developed (completed) if other intangible property.
% of DSHS Funding
Enter the percentage of the "Unit Cost" funded by DSHS.
Life # of Years
Enter the life expectancy of the item as listed in the AHA guidelines.
Acquired Under Program Attachment Number
Enter the program attachment number. For property acquired under TDH, TCADA, and MHMR legacy agency contracts, use the program attachment number under those contracts. For example, substance abuse contractors should use the program number that is submitted on the "Closeout Inventory List" form (i.e. 06-043-051); TDH legacy contractors should use the contract document/attachment number (i.e. 7575757575-2003-01). For property acquired under FY2007 contracts and thereafter, the program attachment number consists of the state fiscal year - documents number - "one up" attachment number (i.e. 2007-020777-001, 2007-020777-02). The program attachment number can be found on the first page of the contract.
DSHS Program
For property acquired under contracts prior to FY2007, use the program name as referenced under each contract. For property acquired under FY2007 contracts and there after, enter the program name as listed on the first page of the contract, found next to the program attachment number (i.e., HIV/PREV).
Location of Item
Enter the physical location where the property is located to include: street address, building number, room number, office name, and other relevant information useful in locating the item.
Current Status
Click the box that reflects the status of the property's use at the time the report is completed. The property may not be in use for various reasons: broken, no longer needed, replaced, in the process of being repaired, etc….
Disposition Date
Specify date of disposition; maintain disposition records on file. Reporting of the disposition information is only required in the reporting year of disposition. The disposed property should not be reported on the following years' Contractor's Inventory Report (Form GC-11).
Sales Price if Sold
Enter sales price rounding to the nearest dollar. Reporting of the disposition information is only required in the reporting year of disposition. The disposed property should not be reported on the following years' Contractor's Inventory Report (Form GC-11).
Reason for Disposition or Reason Item is Not In Use
Enter the reason behind disposing of the item. Reporting of the disposition information is only required in the reporting year of disposition. The disposed property should not be reported on the following years' Contractor's Inventory Report (Form GC-11). Alternatively, enter the reason why the item is not currently in use. The property may not be in use for various reasons: broken, no longer needed, replaced, in the process of being repaired, etc.....

&RLast Revised: May 2016

Example

EXAMPLE
DEPARTMENT OF STATE HEALTH SERVICES
CONTRACTOR'S PROPERTY INVENTORY REPORT (FORM GC-11)
For the period ending August 31, 2016
Organization Name:AAA Health DepartmentPrepared by:Jane Doe
Vendor ID:17429XXXXXXPhone Number:512-458-7111
Address:101 StreetDate Completed:9/1/16
Somewhere, TX 12345
Disposition Information
No.Item DescriptionSerial #Unit Cost (round to nearest $)Acquired (date received)% of

DSHS

Funding Life # of years Acquired Under Program Attachment Number DSHS Program Location of Item Current Status Disposition Date Sales Price

If SoldReason for Disposition or Reason Item is Not in Use
1Desktop Computer - Dell OptiPlex 960;

Intel Core Duo Processor 3.0 GHz 160GB Hard Drive; 4GB DDR2 Memory;

17" Flat Panel Monitor with keyboard and mouse.XX8XXX8$62512/12/12100%32013-55555-555HIV/PREV101 Street Somewhere, Texas 123455/12/16$25No longer used. Past useful life. Replaced.
2Laptop Computer - HP Elitebook; Intel Core Duo Processor 3.0 GHz 160GB Hard Drive; 4GB DDR2 Memory; 15" Monitor.XX8XXX9$55012/12/12100%32013-55555-555HIV/PREV101 Street Somewhere, Texas 123455/12/16$0Damaged. Past useful life. Replaced.
3Laptop Computer - HP Elitebook; Intel Core Duo Processor 3.0 GHz 160GB Hard Drive; 4GB DDR2 Memory; 15" Monitor.XX8XX10$5009/15/15100%32016-55555-545HIV/PREV101 Street Somewhere, Texas 12345N/AN/AN/A
4Laptop Computer - HP Elitebook; Intel Core Duo Processor 3.0 GHz 160GB Hard Drive; 4GB DDR2 Memory; 15" Monitor.XX8XX11$5009/15/15100%32016-55555-562CHS/PHC101 Street Somewhere, Texas 12345N/AN/AN/A
5Laptop Computer - HP Elitebook; Intel Core Duo Processor 3.0 GHz 160GB Hard Drive; 4GB DDR2 Memory; 15" Monitor.XX8XX12$5009/15/15100%32016-55555-562CHS/PHC101 Street Somewhere, Texas 12345N/AN/AItem is in the process of being repaired due to accidental damage.
6
7
8
9
10

&RLast Revised: May 2016 Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use

Criteria

FISCAL YEAR 2016 DEPARTMENT OF STATE HEALTH SERVICES CONTRACT GENERAL PROVISIONS
ARTICLE II COMPLIANCE AND REPORTING
Section 2.02 Precedence of Contract Terms.
To the extent this Contract imposes a higher standard or additional requirements beyond those required by applicable statutes, regulations, rules or executive orders, the terms of this Contract shall take precedence and control.
Section 2.05 Reporting.
Contractor shall submit reports in accordance with the reporting requirements established by the Department and provided for in the Contract and in these General Provisions. Except as otherwise provided for in this Contract or General Provisions, the Contractor shall submit reports to the assigned contract manager. Contractor shall also provide any other information requested by the Department in the format required by DSHS. Failure to submit any required report or additional requested information by the due date specified in the contract or upon request may constitute a breach of contract, result in delayed payment and/or the imposition of sanctions and remedies. And failure to comply with a reporting requirement may adversely affect evaluation of Contractor’s ability to contract in the future with the Department.
ARTICLE XIV GENERAL TERMS
Section 14.06 Other Intangible Property.
At the conclusion of the contractual relationship between Department and Contractor, for any reason, Department shall have the sole ownership rights and interest in all non-copyrightable intangible property that was developed, produced or obtained by Contractor as a specific requirement under this Contract or under any grant that funds this Contract, such as domain names, URLs or software licenses with a value of $500 or more. Contractor shall cooperate with Department and perform all actions necessary to transfer ownership of such property to the Department or its designee, or otherwise affirm Department’s ownership rights and interest in such property. This provision shall survive the termination or expiration of this Contract.
Section 14.22 Insurance.
Contractor shall acquire and maintain for the duration of this Contract, insurance and with financially sound and

reputable insurers licensed by the Texas Department of Insurance, in the type and amount customarily carried within the Contractor’s industry or profession. Contractor must submit evidence of insurance as required under this Contract, including if requested a schedule of coverage or “underwriter’s schedules” establishing to the satisfaction of DSHS the nature and extent of coverage granted by each such policy upon request by DSHS. In the event that any policy is determined to be deficient to comply with the terms of this Contract, Contractor shall secure such additional policies or coverage as DSHS may reasonably request or that are required by law or regulation.

2016 FEDERAL GRANT SUBRECIPIENT

ADDITIONAL PROVISIONS

ARTICLE XX DSHS GENERAL PROVISIONS
In addition to the terms and conditions in the Department of State Health Services (DSHS or Department) FY2016 General Provisions (General Provisions), Contractor agrees to comply with these 2016 Federal Grant Subrecipient Additional Provisions.
ARTICLE XXII PROGRAM EQUIPMENT AND SUPPLIES
Section 22.01 Equipment.
Equipment means tangible personal property having a useful lifetime of more than one year and a per-unit acquisition cost that exceeds the lesser of the capitalization level established by Contractor for financial statement purposes, or $5,000. Contractors shall inventory all equipment, and report the inventory on the Contractors Property Inventory Form.
Contractor shall initiate the purchase of all equipment approved in writing by DSHS, in the first quarter of the Contract or Program Attachment term, as applicable. Failure to timely initiate the purchase of equipment may result in the loss of availability of funds for the purchase of equipment. Requests to purchase previously approved equipment after the first quarter in the Program Attachment must be submitted to the contract manager assigned to this Contract.
Section 22.02 Equipment List.
a. All items of equipment to be purchased with funds under this Contract must be itemized in Contractor’s equipment list as finally approved by the Department in the executed Contract. The equipment list must include: 1. Description of the property;

2. Serial number or other identification number;

3. Source of funding for the property (including the Federal Assistance Identification Number);

4. Who holds title,

5. Acquisition date and cost of the property;

6. Percentage of Federal participation in the project costs for the Federal award under which the property was acquired;

7. Location use and condition of the property; and

8. Any ultimate disposition data including the date of disposal and sale price of property. Any changes to the approved equipment list in the executed Contract must be approved in writing by Department prior to the purchase of equipment.

Contractor shall submit to the contract manager assigned to this Contact, a written description including complete product specifications and need justification prior to purchasing any item of unapproved equipment. If approved, Department will acknowledge its approval by means of a written amendment.
Section 22.03 Supplies.
a. Supplies are defined as consumable items necessary to carry out the services under this Contract including medical supplies, drugs, janitorial supplies, office supplies, patient educational supplies, software, and any items of tangible personal property other than those defined as equipment above.
b. Tangible personal property includes controlled assets, including firearms, regardless of the acquisition cost, and the following assets with an acquisition cost of $500 or more, but less than $5,000, which includes desktop and laptop computers (including notebooks, tablets and similar devices), non-portable printers and copiers, emergency management equipment, communication devices and systems, medical and laboratory equipment, and media equipment are also considered Supplies.
c. Prior approval by DSHS of the purchase of Controlled Assets is not required, but such purchases must be reported on the Contractors Property Inventory Form as detailed under Section 22.04.
Section 22.04 Property Inventory and Protection of Assets.
Contractor shall maintain an inventory of equipment, supplies defined as controlled assets, and property described in Section 14.06 of the General Provisions and submit an annual cumulative report of the equipment and other property on Contractor’s Property Inventory Report to the Department’s Contract Oversight and Support Section, Mail Code 1326, P.O. Box 149347, Austin, Texas 78714-9347, no later than October 15th of each year. The report is located on the DSHS website at: http://www.dshs.state.tx.us/contracts/forms.shtm.
Contractor shall maintain, repair, and protect assets under this Contract to assure their full availability and usefulness.
If Contractor is indemnified, reimbursed, or otherwise compensated for any loss of, destruction of, or damage to the assets provided or obtained under this Contract, Contractor shall use the proceeds to repair or replace those assets.
Section 22.05 Assets as Collateral Prohibited.
Contractors on a cost reimbursement payment method shall not encumber equipment purchased with Department funds without prior written approval from the Department.
ARTICLE XXIV ALLOWABLE COSTS AND AUDIT REQUIREMENTS
Section 24.02 Property Acquisitions.
Department funds must not be used to purchase buildings or real property. Any costs related to the initial acquisition of the buildings or real property are not allowable.
ARTICLE XXV INSURANCE AND BONDS
Section 25.01 Insurance
In addition to the Insurance provision in Section 14.22 of the General Provisions, Contractor shall maintain insurance or other means of repairing or replacing assets purchased with Department funds.
Contractor shall repair or replace with comparable equipment any such equipment not covered by insurance that is lost, stolen, damaged or destroyed. If any insured equipment purchased with DSHS funds is lost, stolen, damaged or destroyed, Contractor shall notify the contract manager assigned to this Contract within 5 business days of learning of the loss, to obtain instructions whether to submit and pursue an insurance claim. Contractor shall use any insurance proceeds to repair the equipment or replace the equipment with comparable equipment or remit the insurance proceeds to DSHS.
ARTICLE XXVI TERMINATION, BANKRUPTCY AND CLOSEOUT
Section 26.02 Bankruptcy.
In the event of bankruptcy, Contractor shall sever Department property, equipment, and supplies in possession of Contractor from the bankruptcy, and title must revert to Department. If directed by DSHS, Contractor shall return all such property, equipment and supplies to DSHS.
Contractor shall ensure that its subcontracts, if any, contain a specific provision requiring that in the event the subcontractor’s bankruptcy, the subcontractor must sever Department property, equipment, and supplies in possession of the subcontractor from the bankruptcy, and title must revert to Department, who may require that the property, equipment and supplies be returned to DSHS.
Section 26.03 Title to Property.
At the expiration or termination of this Contact for any reason, title to any remaining equipment and supplies purchased with funds under this Contract reverts to Department. Title may be transferred to any other party designated by Department. The Department may, at its option and to the extent allowed by law, transfer the reversionary interest to such property to Contractor.
Section 26.04 Disposition of Property.
a. Contractor shall follow the procedures in the American Hospital Association’s (AHA) “Estimated Useful Lives of Depreciable Hospital Assets” in disposing, at any time during or after the Contract term, of equipment purchased with the Department funds, except when federal or state statutory requirements supersede or when the equipment requires licensure or registration by the state, or when the acquisition price of the equipment is equal to or greater than $5,000.
b. All other equipment not listed in the AHA reference (other than equipment that requires licensure or registration or that has an acquisition cost equal to or greater than $5,000) will be controlled by the requirements of UGMS.
c. If, prior to the end of the useful life, any item of equipment is no longer needed to perform services under this Contract, or becomes inoperable, or if the equipment requires licensure or registration or had an acquisition price equal to or greater than $5,000, Contractor shall request disposition approval and instructions in writing from the contract manager assigned to this Contract.
d. After an item reaches the end of its useful life, Contractor shall ensure that disposition of any equipment is in accordance with Generally Accepted Accounting Principles, and any applicable federal guidance.
Section 26.05 Closeout of Equipment.
At the end of the term of a Contract that has no additional renewals or that will not be renewed (Closeout), or when a Contract is otherwise terminated, Contractor shall submit to the contract manager assigned to this, an inventory of equipment purchased with Department funds and request disposition instructions for such equipment.
All equipment purchased with Department funds must be secured by Contractor at the time of Closeout, or termination of this Contract, and must be disposed of according to the Department’s disposition instructions, which may include return of the equipment to DSHS or transfer of possession to another DSHS contractor, at Contractor’s expense.
ARTICLE XXVII NON EXCLUSIVE LIST OF APPLICABLE LAWS
Where applicable, federal statutes and regulations, including federal grant requirements applicable to funding sources, will apply to this Contract. Contractor agrees to comply with applicable laws, executive orders, regulations and policies, as well as Office of Management and Budget (OMB) Circulars (as codified in Title 2 of the Code of Federal Regulations), the Uniform Grant and Contract Management Act of 1981 (UGMA), Tex. Gov. Code Chapter 783, and Uniform Grant Management Standards (UGMS), as revised by federal circulars and incorporated in UGMS by the Comptroller of Public Accounts, Texas Procurement and Support Services Division. UGMA and UGMS can be located through web links on the DSHS website at http://www.dshs.state.tx.us/contracts/links.shtm.
Contractor also shall comply with all applicable federal and state assurances contained in the Uniform Grant Management Standards. If applicable, Contractor shall comply with the Federal awarding agency’s Common Rule, and the U.S. Health and Human Services Grants Policy Statement, both of which may be located through web links on the DSHS website at http://www.dshs.state.tx.us/contracts/links.shtm. For contracts funded by block grants, Contractor shall comply with Tex. Gov. Code Chapter 2105.
DEPARTMENT OF STATE HEALTH SERVICES
CONTRACTOR'S PROPERTY INVENTORY REPORT (FORM GC-11)
For the period ending
Organization Name:Prepared by:
Vendor ID:Phone Number:
Address:Date Completed:
Disposition Information
No.Item DescriptionSerial #Unit Cost (round to nearest $)Acquired (date received)% of

DSHS

Funding Life # of years Acquired Under Program Attachment Number DSHS Program Location of Item Current Status Disposition Date Sales Price

If SoldReason for Disposition or Reason Item is Not In Use
1Dodge Embalming Machines - Quantity=3N/AN/A8/21/08100%Royse City, TX - Storage Facility
2Dodge Wide Blue Smooth Mover - Quantity=3N/AN/A8/21/08100%Royse City, TX - Storage Facility
3Ferno Accordian Trucks - Quantity=3N/AN/A7/8/08100%Royse City, TX - Storage Facility
4Ferno Folding Prep Tables - Quantity=2N/AN/A7/8/20100%Royse City, TX - Storage Facility
5Ferno Maxi Mortuary Cots - Quantity=3N/AN/A8/27/08100%Royse City, TX - Storage Facility
6Free Standing Tents 20X20 - Quantity=3N/AN/A9/16/08100%Royse City, TX - Storage Facility
7Human Remains Smooth Mover - Quantity=3N/AN/A10/28/08100%Royse City, TX - Storage Facility
8Stainless Steel Morgue Trays - Quantity=60N/AN/A7/8/08100%Royse City, TX - Storage Facility
9Body Bags - Quantity=0N/AN/AN/A100%N/A
10State Morgue Trailer #1 - Qty=1N/AN/A2012100%Royse City, TX - Storage Facility
11State Morgue Trailer #2 - Qty=1N/AN/A2012100%Royse City, TX - Storage Facility
12State Morgue Trailer #3 - Qty=1N/AN/A2012100%Royse City, TX - Storage Facility
13State Morgue Trailer #4 - Qty=1N/AN/A2016100%Royse City, TX - Storage Facility
14Commercial Moblie Diesel Electrical Generator - Qty=3N/AN/AOn board state morgue trailers

&RLast Revised: May 2016 Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use Not in Use In Use

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