APPENDIX A 650-25-80

(NEW 7/1/19 ML #3552)

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Instructions for Completion of the Monthly Data & Payment Report (SFN 269).

 

Legal Entity Name, Address, City, State, Zip Code: Complete as included in the contract.

 

Service Period From/Service Period To: Record the service period for which the payment is requested. Recording must include the month, days, and a four-digit year.

 

Contract Number: Record the contract number as it appears on the contract.

 

Vendor Number: Record the Office of Management and Budget (OMB) approved Vendor Number.

 

ASD File Number: Aging Services Division will record the ASD File Number for the first payment request. The contract entity must record the number on subsequent requests for payment.

 

Row A - Nutrition Education: Record the number of units provided during the service period and the dollar value associated with the service.

 

Row B - Nutrition Counseling: Record the number of units provided during the service period and the dollar value associated with the service.

 

Next Row: Record the type of service provided using the Report Service Delivery section in SAMS; select the filter for the provided service.

 

Row C - Unduplicated Individuals Served: Represents the unduplicated number of persons served for the service period. This number is generated automatically in SAMS and will auto-fill into the SAMS report form; the number must be manually entered in the PDF fillable on-line form.

 

Row D- Number of Eligible Units Provided: Represents the number of eligible service units provided for the service period. This number is generated automatically in SAMS and will auto-fill into the SAMS report form; the number must be manually entered in the PDF fillable on-line form.

 

Row E1 – Required Match Balance: Represents the beginning amount of required match that has not been met for the contract term. For the first payment request, the contract entity must record the amount as stated in the contract. For subsequent payment requests, the contract entity must record the amount from Row E3-Balance After Expenditure from the previous service period.

 

Row E2- Required Match Expended: The contract entity must record the amount of required match that will be expended for each of the contracted services for the service period until the match requirement is met for the contract term. To calculate the amount of required match for each service, divide Row I-Service Period Expenditure by .85 (85%) and multiply by .15 (15%).

 

Row E3 – Balance After Expenditure: Represents the balance of required match that has not been met for the contract term. The amount is automatically calculated and will auto-fill into the SAMS report form and the PDF fillable on-line form (Row E1-Required Match Balance minus Row E2-Required Match Expended).

 

Row F1 - Program Income Received: Record the amount of program income received for each service for the service period.

 

Row F2 - Program Income Expended: Record the amount of program income expended for each service for the service period. Program income can only be expended for the service from which it was generated except for congregate and home-delivered meals where it can be applied to either service.

 

Row G - Contracted Unit Rate: Record the contracted unit rate per unit of service as identified in the contract.

 

Row H - Contract Balance: Represents the available balance for the contracted service. This amount will decrease as payments are made. The calculated amount from Row J - Balance After Payment must be recorded by the contract entity in Row H Contract Balance for each subsequent payment request until the contract funds are depleted.

 

Row I - Service Period Expenditure: Represents the amount of payment requested by the contract entity. The Service Period Expenditure must be calculated by the contract entity by multiplying Row D-Number of Eligible Units Provided by Row G-Contracted Unit Rate.

 

Row J - Balance After Payment: Represents the amount of contract funds that have not been expended. This amount is automatically calculated and will auto-fill into the SAMS report form and the PDF fillable on-line form (Row H-Contract Balance minus Row I-Service Period Expenditure Equals Row J-Balance After Payment).

 

Row K - NSIP Payment: Represents the amount of NSIP payment based on the number of meals served during the preceding federal fiscal year and the amount of the State’s NSIP award. NSIP payments will be disbursed upon receipt from the Federal government.

 

Coded Sections: The coded sections are for internal use by the Department of Human Services.

 

Signature Box: Sign and complete title and date fields. By signing, the contract entity certifies compliance with the match requirement as stated in the contract. The completed form must be printed and submitted to Aging Services Division for payment.

 

Other signature lines are for internal use by the Department of Human Services.