FINANC_1.XLS

XLS spreadsheet 450 KB Posted Apr 17, 2024

Attached to: Notification of Funding Availability for FTA Section 5310 Funded Aging Services in Atlanta Region
Solicitation number: PE-29016-NONST-2024-000000005
Issued by: Cherokee County, Georgia

About this file

Written by GovTribe AI · Apr 18, 2024

This document is a Notification of Funding Availability (NOFA) for FTA Section 5310 Funded Aging Services in the Atlanta Region, issued by the Atlanta Regional Commission (ARC) Area Agency on Aging (AAA). The NOFA solicits proposals from potential Offerors interested in providing transportation services and supports for older adults in 11 counties in the Atlanta Region, including Cherokee, Clayton, Cobb, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry, and Rockdale. The contract term is from October 1, 2024 to September 30, 2025, with an option to renew for two additional years. A pre-proposal conference will be held on April 19, 2024, and proposals are due by May 20, 2024.

The NOFA outlines the required information to be included in proposals, such as project intent, county(ies) of service, operating days and hours, vehicle fleet details, and projected service units and persons served. The ARC AAA will provide FTA Section 5310 funding for the selected services, and Offerors are expected to demonstrate their capacity to provide the required match funding and leverage the grant funding to maximize program outcomes. The NOFA also includes a pre-award risk assessment form for potential Offerors.

View the file

Other files

File	Type	Posted
NOFA Directions.docx	DOCX document	Apr 17, 2024
Questions and Answers (pdf).PDF	PDF	Apr 17, 2024
Proposal Response Template FTA 5310 FY25_FY27.docx	DOCX document	Apr 17, 2024
APPLIC_1.DOC	DOC document	Apr 17, 2024
UCM Training Manual.pdf	PDF	Apr 17, 2024
Pre_Proposal Conference _ Additional Information.PDF	PDF	Apr 17, 2024
ARC FTA 5310 FFY25_FFY27 NOFA.pdf	PDF	Apr 17, 2024

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Instructions

FINANCIAL COMPONENTS WORKBOOK

General Requirements:

Project Information

Budget Summary

UCM Personnel

UCM Support

Budget Narrative

Pre-Risk Assessment

*REMINDER: Fill out each tab completely

Project Information

PROJECT INTENT
Indicate the intent of the project with an "X"
Continuing/expanding a service you are currently operating
Beginning a new service you are not currently operating
PROJECT TYPE & COUNTY(IES) OF SERVICE
Indicate the county of clients receiving this service. Mark "X" to all that may apply
	Demand Response	Fixed Route	# of Fixed Routes	Employement	Dialysis	Other Medical	Quality of life

(e.g. grocery, hair, visiting, shopping etc.)

Cherokee

Clayton

Cobb

Dekalb

Douglas

Fayette

Forsyth

Fulton

Gwinnett

Henry

Rockdale

OPERATING DAYS & HOURS
Indicate the days you operate by entering the hours of operation.
	Mon	Tues	Wed	Thur	Fri	Sat	Sun
Hours

Number of Days Transportation Services are Needed Annually

Will you use subcontractors? Yes No

Do you have an in-house fleet? Yes No Total # of passenger seats in fleet

If so, please give description of current vehicle fleet: include DHS owned, and all other vehicles. (Attach additional sheets, if needed)
Year	Make/Model	Capacity (amb / lift)	Owner

Do you have a Volunteer Program? Yes No

Does your agency participate in DHS Coordinated Transportation? Yes No

Number of Persons likely to receive Service (estimate)
	% of Service Area Population	# of Persons expected to be served
White		0
Black		0
Hispanic		0
Asian-Pacific		0
Asian-Indian		0
Native American		0
total	0%	0

&G &"Arial,Bold"&12 5310 Transmittal Cover & Finance Components

Page &P of &N

Budget Summary Table

Offeror Budget Summary Work Sheet

Agency Name:

TOTAL 5310 FUNDING REQUEST

CURRENT # of One Way Trips / Service Hours Served

ESTIMATED # of one-way trips / Service Hours Needed

TOTAL COST OF CURRENT & ANTICIPATED NEED (cost per trip x total trips = total cost)

Service

Unit of measure

Unit Cost (per UCM support)

Individuals with Disabilities (under 65)

Elderly (65+)

Individuals with Disabilities (under 65)

Elderly (65+)

Individuals with Disabilities (under 65)

Elderly (65+)

5310 Funding Request

Units of Service to be provided with ARC Funding

Unduplicated Persons Served by ARC Funding

Projected Units Served: July

Projected Units Served: August

Projected Units Served: September

Projected Units Served: October

Projected Units Served: November

Projected Units Served: December

Projected Units Served: January

Projected Units Served: February

Projected Units Served: March

Projected Units Served: April

Projected Units Served: May

Projected Units Served: June

Demand Response - Individual

one-way trip

$ - 0

one hour

$ - 0

Demand Response - Voucher

one-way trip

$ - 0

one hour

$ - 0

Fixed route

one hour

$ - 0

Total Line Item Cost

Mobility Management

$ - 0

Total

$ - 0

1. Enter Units of Service to be provided from the UCM Support Spreadsheet

2. Enter the Unit Cost of the Service

3. Enter the unduplicated persons expected to be served

4. Enter the ARC funding provided in the allocation that will be used to fund the services.

PERSONNEL

Enter Provider Name:

MOBILITY MANAGEMENT #1

MOBILITY MANAGEMENT #2

MOBILITY MANAGEMENT #3

TRIPS #4

TRIPS #5

TRIPS #6

#10

#11

#12

#13

#14

#15

#16

#17

#18

#19

#20

#21

#22

#23

#24

#25

STAFF LIST

(Paid staff only - do not include volunteers

or other donated)	Number of Staff Positions (Enter number per staff title)	Base Wages (Enter base amount with no benefits included)	Fringe Benefit Rate
(Enter benefit costs by % only)	Fringe Benefit Dollars
(Auto-populates)	Total

Wages and

Benefits (Auto-populates)	Productive Hours (Enter annual productive hours)	General Admin
(Enter % of staff time in admin)	Admin Hours (Auto-populates)	General Admin

Costs

(Auto-populates)

Staff for Building Mainte-

nance (Enter % of staff time)

Shared Building Space Hours

(Auto-populates)

Shared Building Space

(Auto-populates)

HCBS - Transportation - Ind

HCBS - Transportation - Voucher

HCBS - Transportation Fixed Route

HCBS - Transportation - Ind

HCBS - Transportation - Voucher

HCBS - Transportation Fixed Route

Choose a Service

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

W & B

TOTAL

% OF

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

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STAFF TIME

(Enter % of staff time)

COST

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STAFF TIME

(Enter % of staff time)

COST

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STAFF TIME

(Enter % of staff time)

COST

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(Auto-populates)

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STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

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STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

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STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

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STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

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STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

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STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

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STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

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(Auto-populates)

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STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

HOURS

(Auto-populates)

Billable Hours (Direct Service Staff Only)

STAFF TIME

(Enter % of staff time)

COST

(Auto-populates)

PROGRAMS

(Auto-populates)

WAGES

(Auto-populates)

Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Enter Staff Title/Name	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
Client/Meal Transportation Cost Pool Section Only
Driver	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
Driver	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
Driver	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
Driver	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
Driver	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
Driver	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
Driver	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
Driver	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
Driver	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
Driver	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
(The following data calculates automatically - do not enter)
Total Wages and Benefits	0	$0			$0				$0			$0				$0				$0				$0				$0				$0				$0				$0				$0				$0
Percent of Total Wages and Benefits					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 Hours						0		0			0			0				0				0				0				0				0				0				0				0
Unit of Service														1.00				1.00				1.00				1.00				1.00				1.00				1.00				1.00				1.00

Percent of Total Hours 100.00% 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% 100.00%

Column1

Choose a Service

AAA Administration

AAA Advocacy

AAA Coordination

AAA (Gateway_ADRC's Options Couns)

AAA I_A (Gateway_ADRC's) - Ind

AAA Outreach

AAA Program Development

Caregiver - Group (Staff Activity Log)

Caregiver - Case Management - T-Care Ind

Caregiver - Com Ed - PTC -Ind

Caregiver - Clinical Assessment

Caregiver - Driver Assessment

Caregiver - Respite Care In-Home - Ind

Caregiver - Respite Care In-Home - Voucher

Caregiver - Respite Care Out of Home - Ind

Caregiver - Respite Care Out of Home - V

CCSP - Care Coordination

CLP Community Living Program

CLP Financial Management Services

CLP - Monitoring Living Installation

CLP - Monitoring Living Solution

EAP - Elder Abuse Prevention

ELAP - Elderly Legal Assistance Program

HCBS - Adult Day Care - Ind

HCBS - Adult Day Care - Mobile

HCBS - Adult Day Health - Ind

HCBS - Case Management - Ind

HCBS - Community Education - Group

HCBS - Com Education - CDSMP -Ind

HCBS - Counseling - Ind

HCBS - Home Management - Ind

HCBS - Home Mod & Home Repair - Ind

HCBS - Home Sharing & RM Match - Ind

HCBS - Information & Assistance - Ind

HCBS - Interpretation & Translating - Group

HCBS - Material Aid - Ind

HCBS - Material Aid - Voucher

HCBS - Outreach - Ind

HCBS - Senior Recreation - Group

HCBS - Support Group - Ind

HCBS - Telephone Reassurance - Ind

HCBS - Transition Coordination - Ind

HCBS - Transportation - Ind

HCBS - Transportation - Ind (Assisted)

HCBS - Transportation - Voucher

HCBS - Trans - Group (DHR Unified)

HCBS - Vol Dev/Oppor/Service - Group

In-Home - Chore - Ind

In-Home - Emerg Resp Install - Ind

In-Home - Emerg Resp Monitoring - Ind

In-Home - Friendly Visiting - Ind

In-Home - Homemaker - Ind

In-Home - Homemaker - Voucher

In-Home - Personal Care - Ind

Kinship Care - Case Management

Kinship Care - Counseling

Kinship Care - Group (Staff Act Log)

Kinship Care - Respite Care Out of Home

LTCO - Long-term Care Ombudsman

MFP - MDS-Q Options Counseling

MFP - Transition Coordination

N/W - C Meals Management Only

N/W - C Meals Costs Only

N/W - Exer and Phys Fitness - Ind

N/W - Health P/Disease Prev-Group

N/W - Home-Del Meals Manage Only

N/W - Home-Del Meals Meal Cost Only

N/W - Medications Management - Ind

N/W - Nutrition Counseling - Ind

N/W - Nutrition Education - Ind

N/W - Nut./Health Rel/Health Scr - Ind

SCSEP Employment Program - Ind

&"Arial,Bold"&16DHS DIVISION OF AGING SERVICES

UNIFORM COST METHODOLOGY

Personnel Spreadsheet

SFY 2012

&"Times New Roman,Regular"&9MAN 5600, Appendix D UCM Spreadsheet - Final - 6/5/12 &P of &N

SUPPORT

File is..

All Other

In Balance

MOBILITY MANAGEMENT #1

MOBILITY MANAGEMENT #2

MOBILITY MANAGEMENT #3

TRIPS #4

TRIPS #5

TRIPS #6

#10

#11

#12

#13

#14

#15

#16

#17

#18

#19

#20

#21

#22

#23

#24

#25

HCBS - Transportation - Ind

HCBS - Transportation - Voucher

HCBS - Transportation Fixed Route

HCBS - Transportation - Ind

HCBS - Transportation - Voucher

HCBS - Transportation Fixed Route

ERROR:#REF!

Choose a Service

ERROR:#REF!

Choose a Service

All Other

Enter Bldg Space, Line 108

General Administration

COST POOL

Shared Building Space

COST POOL

Client/Meal Transportation COST POOL

Support

COST POOL

Enter Provider Name:

PROPOSED ANNUAL EXPENSES

(Select Line Item from DAS Chart of Accounts)

WAGES & BENEFITS (Auto-populates)	$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
Auto-populates % of Wages and Benefits from Personnel Spreadsheet(1)	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%
Auto-populates % of Hours from Personnel Spreadsheet (1)	100.00%	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%	100.00%

	STAFF TRAVEL EXPENSES
(Auto-populates)	$0
	Staff Mileage/Per Diem Reimbursement	$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
	Volunteer Mileage/Per Diem Reimbursement	$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
	Other Staff Travel Expenses	$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

	VEHICLE OPERATING EXPENSES
(Auto-populates)	$0
	Vehicle Gas & Oil	$0	no driver personnel	$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
	Vehicle Insurance	$0	no driver personnel	$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
	Vehicle Maintenance	$0	no driver personnel	$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
	Other Vehicle Operating Expenses	$0	no driver personnel	$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

BUILDING EXPENSES (Auto-populates)	$0
Building Depreciation	$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
Building Insurance	$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
Building Maintenance/Janitorial	$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
Building Repairs	$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
Rent	$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
Utilities	$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
Other Space Expenses (Security)	$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

COMPUTER OPERATION EXPENSES (Auto-populates)	$0
Computer Purchase	$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
Computer Maintenance	$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
Computer 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
Computer Training	$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
Other Computer Operation Expenses	$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

	CAPITAL EQUIPMENT EXPENSES
(Auto-populates)	$0
	Capital Equipment Depreciation/Usage Fee	$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
	Equipment Maintenance	$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
	Other Equipment Expenses	$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

SUPPLY EXPENSES (Auto-populates)	$0
Advertising	$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
Copy/Printing	$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
Dues/Subscriptions	$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
Employee Testing	$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
Insurance	$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
Office/Paper 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
Postage	$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
Site 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
Telephone & Other Telecommunications	$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
Training/Meeting Expense	$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
Other Supply Expenses	$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

SERVICE CONTRACTS (Auto-populates)	$0
SCSEP	$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
Identify Contract Type	$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
Identify Contract Type	$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
Identify Contract Type	$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
Identify Contract Type	$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

CONGREGATE MEAL EXPENSES (Auto-populates)	$0
Vendor Meal Contract - Congregate	$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
On-Site or Central Kitchen Preparation:
Raw Food Costs	$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
Labor	$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
Utilities	$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
Disposable 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
Transportation Costs	$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
Meal Delivery Costs	$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
Equipment	$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
Taxes	$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
Other Meal Costs (Kinship Care - monthly mtgs)	$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

HOME DELIVERED MEAL EXPENSES (Auto-populates)	$0
Vendor Meal Contract - Home Delivered	$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
On-Site or Central Kitchen Preparation:
Raw Food Costs	$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
Labor	$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
Utilities	$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
Disposable 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
Transportation Costs	$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
Meal Delivery Costs	$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
Equipment	$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
Taxes	$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
Other Meal Costs (List)	$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

OTHER OPERATING COSTS (Auto-populates)	$0
Agency Indirect (Federal Cognizant Agency Only)	$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
Audit/Legal Fees	$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
Profit/Surplus Margin	$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
Other Misc. Operating Costs	$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

	Spreadsheet Check (Auto-populates)	$0
	TOTAL ALLOWABLE COSTS
(Auto-populates)	$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

COST POOL SECTION:

Service Subcontract Allowance (per contract)	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000	$25,000
Contracts over $50,000 Only - Enter Service Subcontract Adjustment (Contract Amount minus $25,000)	$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

Reallocate Support Costs	$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
Auto-populates based on Percent of Total Staff Hours from Personnel	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%	100.00%

Reallocate Shared Building Space		$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
Enter Square Footage Occupied (In Red Only)	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

Reallocate Client Transportation Costs	$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
Auto-populates % of Driver Time Per Program from Personnel		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%	100.00%

Reallocate General Administration Costs	$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
Auto-populates based on Modified Total Direct Costs		$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

TOTAL ACTUAL COSTS BY SERVICE	$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
Enter Number of Billing Units			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
ACTUAL COST PER UNIT OF SERVICE			$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

DONATED PERSONNEL OR

NON-CASH MATCH SECTION

Enter description (Column A) and then $ value (Column B)	$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
Enter description (Column A) and then $ value (Column B)	$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
Enter description (Column A) and then $ value (Column B)	$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
Enter description (Column A) and then $ value (Column B)	$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
Enter description (Column A) and then $ value (Column B)	$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
Enter description (Column A) and then $ value (Column B)	$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
Enter description (Column A) and then $ value (Column B)	$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
Enter description (Column A) and then $ value (Column B)	$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
Enter description (Column A) and then $ value (Column B)	$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
Enter description (Column A) and then $ value (Column B)	$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

Donated Cost Pool Section: $0 $0

Reallocate Donated Building Space	$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
(Auto-populates from Cost Pool Section above)	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

Reallocate Donated Client Transportation Costs	$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
(Auto-populates from Cost Pool Section above)		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%	100.00%

			$0
	Reallocate Donated General Administration		$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
	(Auto-Populates from Cost Pool Section above)				$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
	Spreadsheet Check (Auto-populates)	$0
	TOTAL COSTS
(Plus Donated/Non-Cash Match)	$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
	Number of Billing Units (Auto-populates from Cost Pool Section above)				- 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
	POTENTIAL UNIT COST				$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

&"Arial,Bold"&16DHS DIVISION OF AGING SERVICES UNIFORM COST METHODOLOGY Support Spreadsheet

SFY 2012

&"Times New Roman,Regular"&9MAN 5600, Appendix D UCM Spreadsheet - Final - 6/5/12 &P of &N&"Arial,Bold"

Budget Narrative

BUDGET NARRATIVE

Your Budget Narrative should address the following bullet points:

* The budget justification is clear, logical and specifically describes the program and corresponds with the cost allocation/budget.

* The budget proposal clearly demonstrates capacity to provide required match funds and leverage grant funding to maximize program outcomes.

**The three spaces below are meant to be for separate paragraphs for your narrative. If you need more or less room, feel free to format as needed.**

Pre-Award Risk Assessment

Contractor Name:		Yes	Yes	5
CFDA/Contract/Grant Award Number(s):		No	No	10
Division/Program Name(s):			N/A	15
Risk Assessment Completed by:				20
Risk Assessment Completed Date:		X		25
Contract/Grant Period(s):				30
Contract/Grant Amount(s):				35
Total Score:	0
Risk Level:	Low Risk

1. Amount	Small <$25,000	Medium	Large
		$25,000 to $250,000	>$250,000
Amount of the award (If award amount is unknown, an estimated award amount should be used.)				0	0	0

2. Accounting System	Automated	Manual	Combination
Type of accounting system used by the entity				0	0	0

3. Program Complexity		Slightly Complex	Moderately Complex	Highly Complex
Rate the complexity of the program					0	0	0	0
Programs with complex compliance requirements have a higher risk of non-compliance. In your determination of complexity consider whether there are complex contract/grant requirements (If you choose one item, select slightly complex; if you choose two items, select moderately complex; if you choose three or four items, select highly complex). The following are some examples of reasons a program would be considered more complex:
► Complex programmatic requirements and/or must adhere to regulations	► Various types of program reports are required
► Matching funds or Maintenance of Effort are required	► The entity further subcontracts out the program
4. Entity Risk				Yes/No
Rank the entity based on your knowledge of the following:
a. Is the entity receiving an award for the first time?					0
b. Did the entity adhere to all terms and conditions of prior grant awards?					0
c. Does the entity have adequate and qualified staff to comply with the terms of the contract/grant?					0
d. Does the entity have prior experience with similar programs?					0
e. Does the entity maintain policies which include procedures for assuring compliance with the terms of the contract/grant?					0
f. Does the entity have an accounting system that will allow them to completely and accurately track the receipt and disbursements of funds related to the contract/grant?					0
g. Does the federal/state program require staff to track their time associated with the contract/grant?
h. If yes, does the entity have a system in place that will account for 100% of each employee's time? (If answered no to 4g, leave blank)					0
i. Did the entity's key staff members attend required trainings and meetings during prior contract/grant awards?					0
j. Did the entity's key staff members respond to State requests timely during prior contract/grant awards?					0
k. Did the entity have one or more audit findings in their last audit and/or single audit regarding program non-compliance?					0
l. Did the entity have one or more audit findings in their last audit and/or single audit regarding significant internal control deficiency?					0
m. Was the entity audited by the Federal government in the prior year(s)?					0
n. If yes, did the audit result in one or more audit finding? (If answered no to 4m, leave blank)					0
(Assign 5 points for each issue below (1-7) that are applicable)	Briefly explain which numbers were chosen and why.
o. Other issues that may indicate high risk of non-compliance?	We had no compliance issues and we have adequate systems to segregate indirect from direct
Other issues: (1) Having new or substantially changed systems or software packages, i.e. accounting, payroll, technology; (2) Turnover in personnel, i.e. business, award management, program; (3) External risks including: economic conditions, political conditions, regulatory changes; (4) Loss of license or accreditation to operate program; (5) New activities, products, or services; (6) Organizational restructuring; (7) Where indirect costs are included, does the organization have adequate systems to segregate indirect from direct costs.
5. Reporting & Budget				Yes/No
Rank the entity based on your knowledge of the following:
a. Were performance reports submitted timely for prior contract/grant awards? (i.e. within the agency specified timeframe)					0
b. Was reasonable progress made towards performance goals for prior contract/grant awards?					0
c. Were financial reports (i.e. expenditure) submitted timely for prior contract/grant awards?					0
d. Were financial reports (i.e. expenditure) accurate for prior contract/grant awards?					0
e. Did the entity stay on budget in prior year(s)?					0
Low = 0 - 85 Moderate = 86 - 170 High = 170 and higher		TOTAL RISK POINTS:		0

Common Attributes of Grantees with Low, Moderate and High Risk:
Low Risk	High Risk
Most of the following attributes should be present to be considered low risk	One or more of the following attributes may be present to be considered high risk
► Entity has complied with the terms and conditions of prior grant awards.	► History of unsatisfactory performance or failure to adhere to prior grant terms and conditions
► No known financial management problems or financial instability	► Financial management problems and/or instability; inadequate financial management system
► High quality programmatic performance	► Program has highly complex compliance requirements
► No, or very insignificant, audit or other monitoring findings	► Significant findings or questioned costs from prior audit
► Timely and accurate financial and performance reports	► Untimely, inadequate, inaccurate reports
► Program likely does not have complex compliance requirements	► Recurring/unresolved issues
► Entity has received some form of monitoring (e.g., single audit, on-site review, etc.)	► Lack of contact with entity or any prior monitoring
	► Large award amount
Moderate Risk ► Entities that fall between low risk and high risk are considered moderate risk.
Considerations/Justification/Notes specific to the Contractor/Grantee:

Completed by: ________________________________________ Title:_________________________ Date:_______________________

Contractor/Grantee has been deemed moderate/high risk. To acknowledge the use of a moderate/high risk contractor/grantee, the division director/program manager is required to sign.

Name: ____________________________________________________ Title:__________________________ Date:________________________

&"Arial,Regular"&12&G

&"Arial,Bold"&18Pre-Award Risk Assessment Form

&"Arial,Regular"&9Pre-Award Risk Assessment.2021 &"Arial,Regular"&9Page &P image1.jpeg image2.png

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