Form_5_-_Expenditure_Worksheet_-_Year_2.pdf
PDF 243 KB Posted
- Attached to
- Opioid Settlement Grants FY26
- Solicitation number
- 2025-RFP-011
- Issued by
- Mohave County, Arizona
About this file
The document is Form 5 - Expenditure Worksheet for Opioid Settlement Funding, designed for organizations to report quarterly expenditures for the period of July 1, 2026 through June 30, 2027. The form requires detailed financial reporting for organizations receiving opioid settlement funds, including a comprehensive breakdown of direct program costs such as personnel salaries, operating expenses, and indirect costs. Organizations must track and report expenditures across four quarterly periods, with line items for categories like travel, outreach, staff education and training, supplies, materials, and equipment.
The worksheet mandates extensive documentation and transparency, requiring organizations to provide a narrative description of project activities, accomplishments, challenges, staffing changes, budget status, and evaluation metrics. Organizations must include supporting documentation like paid invoices, timesheets, training materials, and travel reports. The form also requires disclosure of any additional opioid settlement funds received from other agencies, with a strict requirement that indirect costs not exceed 10% of the total budget. The purpose appears to be ensuring precise financial accountability and tracking of how opioid settlement funds are utilized by recipient organizations.
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Other files
| File | Type | Posted |
|---|---|---|
| Opioid_Settlement_Grants_FY26.pdf | ||
| AD79810_jnl.pdf | ||
| Form_4_-_Expenditure_Worksheet_-_Year_1.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, 2026 - June 30, 2027
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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