Form_4_-_Expenditure_Worksheet_-_Year_1.pdf
PDF 245 KB Posted
- Attached to
- Opioid Settlement Grants FY26
- Solicitation number
- 2025-RFP-011
- Issued by
- Mohave County, Arizona
About this file
The document is a Form 5 Expenditure Worksheet for an Opioid Grant Reporting Template, covering the period from July 1, 2025, to June 30, 2026. The form is designed for organizations to report detailed financial and programmatic information related to Opioid Settlement Funding. It requires comprehensive reporting on project activities, including a narrative description of achievements, accomplishments and challenges, staffing changes, budget status, evaluation metrics, and any additional Opioid Settlement Funding received from other agencies.
The worksheet provides a structured format for tracking direct program costs, including personnel expenses (salaries and employee-related expenses), operating costs (travel, outreach, staff education and training, supplies, materials, and equipment), and indirect costs (limited to 10% of total budget). Organizations must break down expenditures by quarter, documenting budgeted amounts, actual spending, and remaining balance across various cost categories. The form emphasizes the need for supporting documentation such as paid invoices, timesheets, training materials, and travel reports to substantiate the reported expenses and ensure transparent use of Opioid Settlement Funds.
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Other files
| File | Type | Posted |
|---|---|---|
| Opioid_Settlement_Grants_FY26.pdf | ||
| AD79810_jnl.pdf | ||
| Form_5_-_Expenditure_Worksheet_-_Year_2.pdf | ||
| City_Procurement_Code_of_the_City_of_Kingman_2020-03.pdf | ||
| EXHIBIT_1.pdf |
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Text version
FORM 5 - Expenditure Worksheet-July 1,2025 - June 30, 2026
Organization Name:
Address:
Contact Person: ____________________________________ Contact Telephone:
Reporting Period (Quarter): _________________ Amount Spent (must match worksheet):
1. Narrative description of project activities achieved during specified timeframe:
2. Accomplishments (“success stories”) and challenges:
3. Staffing changes:
4. Current budget and description of over or underspending:
5. Evaluation metrics (e.g., actual numbers served versus proposed numbers):
6. Did you receive and/or use any other Opioid Settlement Funding from another agency? Explain:
7. Activity Attachments (brochures, flyers, voucher copy, newsletters, website page, etc.):
Expenditures: Please provide a breakdown of funds used during the reporting period. Include all supporting documentation (i.e., paid invoices, timesheets, training materials, travel reports, etc.). If you received and used other Opioid Settlement Funds from another agency, please be sure to indicate on the Expenditure Worksheet.
FORM 5 - OPIOID GRANT REPORTING TEMPLATE, Continued
EXENDITURE WORKSHEET
Report amount spent each quarter.
DIRECT PROGRAM COSTS
Budgeted Amount
1ST
Quarter
2nd Quarter
3rd Quarter
4th Quarter Balance
Personnel
Salaries
Position: %
FTE
1 Total Salaries
2 ERE rate: %
3 Personnel Subtotal (1-2) Operating
4 Travel
5 Outreach
6 Staff Education and Training
7 Supplies/Materials
8 Equipment
9 Other:
10 Other:
11 Operating Subtotal (4-10)
12 INDIRECT COSTS (not to exceed 10%)
TOTAL BUDGET (3, 11 & 12)
OTHER OPIOID SETTLEMENT FUNDS
RECIEVED
| FORM 5 - Opioid Grant Reporting Template |
| FORM 5 - OPIOID GRANT REPORTING TEMPLATE |
| FORM 5 - Opioid Grant Reporting Template, continued |
| FORM 5 - OPIOID GRANT REPORTING TEMPLATE, Continued |
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