Y22-115_Exhibit_1_Orlando_EMA_Ryan_White_Part_A_Program_Budget_Template_Sample.xls
XLS spreadsheet 114 KB Posted
- 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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Text version
Instructions
| Orlando EMA Ryan White Part A Program | |
| FY 2021 -22 / BUDGET | |
| Instructions | |
| FORM F101 | |
| 1 | This 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. |
| 2 | Once 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 | |
| 1 | This 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. |
| 2 | This 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. |
| 3 | Once 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 | |
| 1 | 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. |
| 2 | This form must list all the Program Income expenses per service categories and per month. |
| 3 | This 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 31,2021 | Friday, July 9, 2021 |
| June 1, 2021 - August 31, 2021 | Friday, October 8, 2021 |
| September 1, 2021 - November 30, 2021 | Friday, January 7, 2022 |
| December 1, 2021 - February 28, 2022 | Friday, 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 Categories | Original Budget | Amended Budget | March | April | May | June | July | Aug | Sept | Oct | Nov | Dec | Jan | Feb | Exp YTD | Available | % 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 | - 0 | 0% |
| Total Indirect Cost (10% of Direct Cost) | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | 0% | |
| TOTAL Delivery Order | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | - 0 | 0% |
| 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, Title | Signature | Date | |||||||||||||||
| 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 2022 | Funding Sources for Position (Including Benefits) | |||||||||
| Name | Total Salary with Benefits | FTE (% Covered by RWPA) | Title | Brief Job Description | Part A | Part A MAI | Part B | Part C | Other Funds | Total 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 | ||||||||||||
| Categories | March | April | May | June | July | Aug | Sept | Oct | Nov | Dec | Jan | Feb | Exp 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, Title | Signature | Date | |||||||||||
| 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 .