Y22-115_Exhibit_1_Orlando_EMA_Ryan_White_Part_A_Program_Budget_Template_Sample.xls

XLS spreadsheet 114 KB Posted

Attached to
Outpatient ambulatory Health Services for Persons with HIV (Ryan White Part A)
Solicitation number
Y22-115
Issued by
Orange County, Orlando City, Florida

About this file

This file contains budget and staffing documentation for the Orlando Eligible Metropolitan Area (EMA) Ryan White Part A Program for fiscal year 2021-2022, involving Orange County, Florida's HIV health services contract. The solicitation is for Outpatient Ambulatory Health Services for Persons with HIV, with sealed responses due by 4:00 pm EST on March 17, 2022, to be submitted through the OpenGov e-Procurement Platform. The contract covers a full fiscal year from March 2021 to February 2022, with quarterly budget reporting requirements and specific submission deadlines for expenditure tracking.

The documentation includes three primary forms: Form F101 (budget tracking), Form F102 (staffing plan), and Form F103 (program income reporting). Budget guidelines specify that indirect costs cannot exceed 10% of the total delivery order amount, and each form must be completed fully and submitted by established quarterly deadlines. The budget categories encompass direct costs such as salaries, benefits, travel, supplies, office expenses, and utilities, with detailed monthly tracking of expenditures. Funding sources include Ryan White Part A, Part A MAI (Minority AIDS Initiative), Part B, Part C, and potential other funds, covering core services like outpatient ambulatory health services, medical case management, mental health services, and support services for HIV patients.

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Instructions

Orlando EMA Ryan White Part A Program
FY 2021 -22 / BUDGET
Instructions
FORM F101
1This Form must be completed in full once contract is executed and every quarter This is a required form and must be submitted by the established deadline in order to be considered in compliance with the terms of the contract.
2Once final amount has been approved by the Recipient, the total amount must not exceed Delivery Order Amount. Indirect shall not exceed 10% of total Delivery Order Amount.
FORM F102
1This Form must be completed in full once contract is executed and every quarter. This is a required form and must be submitted by the established deadline in order to be considered in compliance with the terms of the contract.
2This form must list all employees directly providing services to Ryan White Part A Consumers. Salaries/benefits, title, job description, and funding source should be completed for each employee.
3Once final amount has been approved by the Recipient, the total amount must not exceed Delivery Order Amount. Indirect shall not exceed 10% of total Delivery Order Amount.
FORM F103
1This is a required form and must be submitted by the established deadline in order to be considered in compliance with the terms of the contract.
2This form must list all the Program Income expenses per service categories and per month.
3This form must be completed for each source of Program Income.

Submission Dates

FY 21-22 Quarterly Budget Expenditures Timeline
Period Coverage (Actual Expenditures)Due Dates
March 1, 2021 - May 31,2021Friday, July 9, 2021
June 1, 2021 - August 31, 2021Friday, October 8, 2021
September 1, 2021 - November 30, 2021Friday, January 7, 2022
December 1, 2021 - February 28, 2022Friday, April 8, 2022

Form F101

Orlando EMA Ryan White Part A Program
AGENCY NAME
FY 2021 - 22 / BUDGET
FORM F101
TYPE OF SERVICE:
CONTRACT NUMBER:
CONTRACT AMOUNT:
DELIVERY ORDER NUMBER:
Budget CategoriesOriginal BudgetAmended BudgetMarchAprilMayJuneJulyAugSeptOctNovDecJanFebExp YTDAvailable% Spent
Monthly Reimbursement- 0- 0- 0
Direct Costs
Salaries- 0- 0- 0
Benefits- 0- 0- 0
Travel- 0- 0- 0
Supplies- 0- 0- 0
Cell Phone- 0- 0- 0
Office Phone/Internet- 0- 0- 0
Office Space- 0- 0- 0
Printing/Reproduction- 0- 0- 0
Office/lawn maintenance- 0- 0- 0
Equipment maintenance- 0- 0- 0
Utilities- 0- 0- 0
Postage- 0- 0- 0
Worker Compensation- 0- 0- 0
Total Direct Costs- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 00%
Total Indirect Cost (10% of Direct Cost)- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 00%
TOTAL Delivery Order- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 00%
Diference- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0- 0
To be Retuned
I certify that the above report is true, accurate and correct reflection of the activities during the reflected period; and that the expenditures reported are made only for items which are allowable and directly related to the purpose of the contract referenced above.
Printed Name, TitleSignatureDate
Form 101 must be submitted to the Recipient once Contract is issued and then on a quarterly basis. Updated March 2021

Form F102

Orlando EMA Ryan White Part A Program
AGENCY NAME
FY 2021 - 22 / STAFFING PLAN
FORM F102
TYPE OF SERVICE:0
CONTRACT NUMBER:0
CONTRACT AMOUNT:$0
DELIVERY ORDER NUMBER:0
DIRECT COST
Staffing Plan March 2021 - February 2022Funding Sources for Position (Including Benefits)
NameTotal Salary with BenefitsFTE (% Covered by RWPA)TitleBrief Job DescriptionPart APart A MAIPart BPart COther FundsTotal Amount
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0$0$0$0$0$0
Budget Form 101 Salary and Benefits$0

Form F103

Orlando EMA Ryan White Part A Program
AGENCY NAME
FY 2021 - 22 / BUDGET
FORM F103 / Program Income
SOURCE OF PROGRAM INCOME:
TOTAL PROGRAM INCOME:
AVAILABLE PROGRAM INCOME:- 0
CategoriesMarchAprilMayJuneJulyAugSeptOctNovDecJanFebExp YTD
Core Services
OAHS$0
OAHS - MAI$0
Local Pharmacy$0
Oral Health Care$0
EIS - MAI$0
ACA$0
Mental Health Services$0
Medical Nutrition$0
MCM$0
Substance Abuse$0
Total Core Cost$0$0$0$0$0$0$0$0$0$0$0$0$0
Support Services$0
Referral Support$0
Food Bank$0
Transportation$0
PEER$0
EFA$0
S.A. Residential$0
Total Support Cost$0$0$0$0$0$0$0$0$0$0$0$0$0
Total Administrative Cost$0
TOTAL Program Income$0$0$0$0$0$0$0$0$0$0$0$0$0
I certify that the above report is true, accurate and correct reflection of the activities during the reflected period; and that the expenditures reported are made only for items which are allowable and directly related to the purpose of the contract referenced above.
Printed Name, TitleSignatureDate
Form 103 must be submitted to the Recipient on a quarterly basis. Updated March 2021

File details come from the government source that posted it. Updated .