Budget, Personnel, and Expense Schedules by Ng6zci

VIEWS: 11 PAGES: 16

									                        DANE COUNTY DEPARTMENT OF HUMAN SERVICES
                               FORMS AND INSTRUCTIONS
                                 TABLE OF CONTENTS
                                                                   PAGE NO.
      1   PROVIDER AGENCY PROGRAM BUDGET SCHEDULE                      2
      2   PROVIDER AGENCY PROGRAM BUDGET SCHEDULE INSTRUCTIONS         3
      3   PROVIDER AGENCY PERSONNEL SCHEDULE                           4
      4   PROVIDER AGENCY PERSONNEL SCHEDULE INSTRUCTIONS              5
      5   PROVIDER AGENCY EXPENSE REPORT                               6
      6   PROVIDER AGENCY EXPENSE REPORT INSTRUCTIONS                  7
      7   PAYMENT VOUCHER AND EXPENSE REPORT DEADLINES                 8
      8   REVISION REQUEST - PAGE 1                                    9
      9   REVISION REQUEST - PAGE 2                                   10
     10   REVISION REQUEST - PAGE 3                                   11
     11   REVISION REQUEST INSTRUCTIONS                              12-13
     12   DEFINITION & CLASSIFICATION GUIDELINES OF ADMINISTRATIVE
          AND PROGRAM COSTS                                          14-15
     13   BUDGET LINE ITEM EXPENSE GUIDELINES                         16




bca1206e-acba-4fe3-b551-c2d3347824ba.xls - Table of Contents        Page 1 of 16
DANE COUNTY DEPARTMENT OF HUMAN SERVICES                                                   PROVIDER AGENCY PROGRAM BUDGET SCHEDULE
                                                                                                                                                     APPROVALS:                  SIGNATURE                               DATE
                      Provider Name:                                                                        Contract #         Program Group #       County:
                      Program Name:                                                                                                                  Provider:

                                                                PRIOR YEAR --2010 FINAL COUNTY APPROVED                                                                      CURRENT YEAR -- 2011
                                                      1                     2                3                  4                     5                       6                      7                  8                  9
                                                                        COUNTY            COUNTY             COUNTY                                       COUNTY                  COUNTY             COUNTY         PERCENT TO
                                                  TOTAL                 FUNDED            FUNDED             FUNDED                TOTAL                  FUNDED                  FUNDED             FUNDED        TOT CO FUNDED
                                                 BUDGET               ( = Col 3 + 4)       ADMIN            PROGRAM               BUDGET                ( = Col 7 + 8)             ADMIN            PROGRAM        (=Col 6/Col 6 Tot)
A. PERSONNEL
   Salaries                                                                            0                                                                                 0                                                   #DIV/0!
   Taxes                                                                               0                                                                                 0                                                   #DIV/0!
   Benefits                                                                            0                                                                                 0                                                   #DIV/0!
                          Subtotal A                            0                      0               0                 0                       0                       0                   0                0              #DIV/0!
B. OPERATING
   Insurance                                                                           0                                                                                 0                                                   #DIV/0!
   Professional Fees                                                                   0                                                                                 0                                                   #DIV/0!
   Audit                                                                               0                                                                                 0                                                   #DIV/0!
   Data Processing                                                                     0                                                                                 0                                                   #DIV/0!
   Postage, Office, and Program Supplies                                               0                                                                                 0                                                   #DIV/0!
   Equipment/Furnishings                                                               0                                                                                 0                                                   #DIV/0!
   Depreciation                                                                        0                                                                                 0                                                   #DIV/0!
   Telephone                                                                           0                                                                                 0                                                   #DIV/0!
   Training/Conference                                                                 0                                                                                 0                                                   #DIV/0!
   Food/Household Supplies                                                             0                                                                                 0                                                   #DIV/0!
   Auto Allowance                                                                      0                                                                                 0                                                   #DIV/0!
   Vehicle Costs                                                                       0                                                                                 0                                                   #DIV/0!
   Other1:                                                                             0                                                                                 0                                                   #DIV/0!
   Other2:                                                                             0                                                                                 0                                                   #DIV/0!
                          Subtotal B                            0                      0               0                 0                       0                       0                   0                0              #DIV/0!
C. SPACE
   Rent                                                                                0                                                                                 0                                                   #DIV/0!
   Utilities                                                                           0                                                                                 0                                                   #DIV/0!
   Maintenance                                                                         0                                                                                 0                                                   #DIV/0!
   Mortgage Interest, Depreciation                                                     0                                                                                 0                                                   #DIV/0!
   Property Taxes                                                                      0                                                                                 0                                                   #DIV/0!
                          Subtotal C                            0                      0               0                 0                       0                       0                   0                0              #DIV/0!
D. SPECIAL COSTS
   Assistance to Individuals                                                           0                                                                                 0                                                   #DIV/0!
                          Subtotal D                            0                      0               0                 0                       0                       0                   0                0              #DIV/0!
E. OTHER (Specify)
   Other3:                                                                             0                                                                                 0                                                   #DIV/0!
   Other4:                                                                             0                                                                                 0                                                   #DIV/0!
                          Subtotal E                            0                      0               0                 0                       0                       0                   0                0              #DIV/0!
This section for Adult - DD only.
F. OFF-SETTING REVENUE
   Show as negative numbers:
   Government Benefits (SSI, SSDI, etc.)                                               0                                                                                 0                                                   #DIV/0!
   Private Pay (Trust Funds, etc.)                                                     0                                                                                 0                                                   #DIV/0!
   Cost Share                                                                          0                                                                                 0                                                   #DIV/0!
   Other                                                                               0                                                                                 0                                                   #DIV/0!
                         Subtotal F                             0                      0               0                 0                       0                       0                   0                0              #DIV/0!
           TOTAL A THROUGH F                                    0                      0               0                 0                       0                       0                   0                0              #DIV/0!

                                          Prior Year Agency Administrative Cost Percent:          #DIV/0!                    Agency Administrative Cost Percent:                        #DIV/0!

              bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 1 Program Budget                                                                                                                                     Page 2 of 16
                        DANE COUNTY DEPARTMENT OF HUMAN SERVICES
           PROGRAM BUDGET SCHEDULES MUST BE PRESENTED USING THE ATTACHED FORMATS

                                                                  Program Budget Instructions

           Provider
           Name              Enter legal name per current Dane County Contract Agreement.

           Program
           Name              Enter name of the program identified in your current Dane County Contract Agreement.

           Contract # Enter the current contract number.

           Program           Enter the current Program Group number provided by Dane County staff. It can be found on the
           Group #           Program Summary Form of the contract.

           Column 1 PRIOR YEAR TOTAL BUDGET. This is the total amount most recently budgeted for this
                    program in the prior year. Use the amounts from your final approved (that is, signed by both
                    your agency and the County) Program Budget of the prior year.

           Column 2 PRIOR YEAR COUNTY FUNDED. This is the County-funded portion of the total budget.
                    Column 3 + Column 4 equals this column. No entries needed in this column if using EXCEL
                    Spreadsheet. It will calculate automatically.

           Column 3 PRIOR YEAR COUNTY FUNDED ADMIN. This is the Admin portion of the prior year
                    County-funded budget.

           Column 4 PRIOR YEAR COUNTY FUNDED PROGRAM. This is the Program portion of the prior year
                    County-funded budget.

           Column 5 CURRENT YEAR TOTAL BUDGET. This is the total amount budgeted for this program in the
                    current year.

           Column 6 CURRENT YEAR COUNTY FUNDED. This is the County-funded portion of the total budget.
                    Column 7 + Column 8 equals this column. No entries needed in this column if using EXCEL
                    Spreadsheet. It will calculate automatically.

           Column 7 CURRENT YEAR COUNTY FUNDED ADMIN. Using the County’s definition of Admin,
                    distribute the costs in column 6 between this column and column 8.

           Column 8 CURRENT YEAR COUNTY FUNDED PROGRAM. Costs not classified as Admin are
                    classified as Program. This column equals Column 6 minus Column 7.

           Column 9 PERCENT TO TOTAL COUNTY FUNDED. No entries needed in this column if using the
                    EXCEL Spreadsheet. It will calculate automatically.

                             PRIOR YEAR AGENCY ADMINISTRATIVE COST PERCENT. This reflects the prior year
                             administrative cost percent. Column 3 Prior year County Funded Admin divided by column 2
                             Prior year County Funded.

                             AGENCY ADMINISTRATIVE COST PERCENT. This reflects the current year administrative
                             cost percent. Column 7 County Funded Admin divided by column 6 County Funded.

           SIGN AND DATE DOCUMENT ON THE PROVIDER APPROVAL LINE



bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 2 Program Budget Instructions                                                    Page 3 of 16
DANE COUNTY DEPARTMENT OF HUMAN SERVICES
PROVIDER AGENCY PERSONNEL SCHEDULE
                                                                                                                     APPROVALS:                                     SIGNATURE                                        DATE
                   Provider Name:                                                                                     Contract #         Program Group #           County:
                  Program Name:                                                                                                                                    Provider:

NOTE: In General, 1 FTE = 2080 hours. Divide total hours for the position/category by 2080 to get the number of FTEs. Match total salary for the position/category to the number of FTEs.


                                                          PRIOR YEAR --2010 FINAL COUNTY APPROVED                                                                 CURRENT YEAR -- 2011
                                                      1               2               3           4                        5             5a            6                7                8            9               10
                                                                    COUNTY                                                                         COUNTY                                      AVERAGE         AVERAGE
                                               COUNTY               FUNDED            COUNTY          COUNTY          COUNTY           FTE         FUNDED            COUNTY         COUNTY     ANNUAL          HOURLY
STAFF POSITION/CATEGORY                        FUNDED              SALARY *           FUNDED          FUNDED          FUNDED          BASIS       SALARY *           FUNDED         FUNDED      SALARY          SALARY
                                                 FTE              ( = Col 3 + 4)      ADMIN *        PROGRAM *          FTE                      ( = Col 7 + 8)      ADMIN *       PROGRAM * (= Col 6/Col 5) (=Col 9/Col 5a)
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                                                                               0                                                         2,080                0                                     #DIV/0!         #DIV/0!
                              TOTAL                    0.0000                  0                 0               0          0.0000                            0                0           0     #DIV/0!

                                                                                   * NOTE: Do not include taxes and benefits in the salary amounts on this page.




        bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 3 Pers Sched                                                                                                                                       Page 4 of 16
                                                     DANE COUNTY DEPARTMENT OF HUMAN SERVICES
                                          PERSONNEL SCHEDULES MUST BE PRESENTED USING THE ATTACHED FORMATS

                                                                           Personnel Schedule Instructions

              Provider Name                Enter legal name per current Dane County Contract Agreement.

              Program Name                 Enter name of the program identified in your current Dane County Contract Agreement.

              Contract #                   Enter the current contract number.

              Program Group #              Enter the current Program Group number provided by Dane County staff. It can be found on the
                                           Program Summary Form of the contract.

                                           List by title each position included in the prior year and current year budgets. Please be
              Staff Position/              consistent and use the same position title if the same position appears in more than one program.
              Category                     Do not fill in the name of the individual person working in the position. If there is money listed
                                           in county funded admin or program fields the position/category must be filled in.

              Column 1                     PRIOR YEAR COUNTY FUNDED FTE. Show the number of FTEs for each position funded
                                           by Dane County in the final prior year Personnel Schedule.

              Column 2                     PRIOR YEAR COUNTY FUNDED SALARY. Show the amount budgeted for each position
                                           funded by Dane County in the final prior year Personnel Schedule. The bottom line of this
                                           column should equal the amount on the Program Budget Salaries line - Column 2. No entries
                                           needed in this column if using the EXCEL Spreadsheet. If not using the Spreadsheet, Column 3
                                           + Column 4 = Column 2.

              Column 3                     PRIOR YEAR COUNTY FUNDED ADMIN. These are the prior year County-funded Admin
                                           salaries shown in the final prior year Personnel Schedule. The bottom line of this column should
                                           equal the amount on the Program Budget Salaries line – Column 3.

              Column 4                     PRIOR YEAR COUNTY FUNDED PROGRAM. These are the prior year County-funded
                                           Program salaries shown in the final prior year Personnel Schedule. The bottom line of this
                                           column should equal the amount on the Program Budget Salaries line – Column 4.

              Column 5                     CURRENT YEAR COUNTY FUNDED FTE. Show the number of FTEs for each position
                                           funded by Dane County in current year.

              Column 5a                    FTE BASIS. For those agencies where 37.5 hours per week (1,950 hours per year) or some other
                                           amount is considered full-time, please indicate the annual number of hours for 1 FTE in Column
                                           5a by overwriting or crossing out the 2,080 (1 FTE for 40 hours per week) that is shown and
                                           replacing it with your FTE basis. It is expected that your FTE basis will be consistent across all
                                           programs and listed positions.

              Column 6                     CURRENT YEAR COUNTY FUNDED SALARY. Show the amount budgeted for each
                                           position funded by Dane County in current year. The bottom line of this column should equal
                                           the amount on the Program Budget Salaries line - Column 6. No entries needed in this column if
                                           using the EXCEL Spreadsheet. If not using the Spreadsheet, Column 7 + Column 8 = Column 6.


              Column 7                     CURRENT YEAR COUNTY FUNDED ADMIN. Using the County’s definition of Admin,
                                           distribute the salary for each postition between this column and column 8. The bottom line of
                                           this column should equal the amount shown on the Program Budget Schedule - County Funded
                                           Admin Salaries(Column 7). For each position, Column 7 + Column 8 = Column 6.

              Column 8                     CURRENT YEAR COUNTY FUNDED PROGRAM. These are the current year County-funded
                                           Program salaries. The bottom line of this column should equal the amount on the Program
                                           Budget Schedule - County Funded Program Salaries(Column 8). For each position, Column 7 +
                                           Column 8 = Column 6.

              Column 9                     CURRENT YEAR AVERAGE ANNUAL SALARY. No entries needed in this column if using
                                           the EXCEL Spreadsheet. It will calculate automatically. If not using Spreadsheet, Column 6
                                           divided by Column 5 = Average Annual Salary.

              Column 10                    CURRENT YEAR AVERAGE HOURLY SALARY. No entries needed in this column if using
                                           the EXCEL Spreadsheet. It will calculate automatically. If not using Spreadsheet, Column 9
                                           divided by Column 5a = Average Hourly Wage.

              SIGN AND DATE DOCUMENT ON THE PROVIDER APPROVAL LINE

bca1206e-acba-4fe3-b551-c2d3347824ba.xls -4 Pers Sched Instructions                                                                             Page 5 of 16
DANE COUNTY DEPARTMENT OF HUMAN SERVICES                                PROVIDER AGENCY EXPENSE REPORT THROUGH:

Provider Name:                                                                      Contract #:                                 *Provider Certified By:
Program Name:                                                                 Program Group #:                                                                                                  Date

                                                        1                         2                          3                                4                           5                       6
                                                    Approved                    YTD                         YTD                             YTD                         YTD                     YTD
                                                  County-Funded             County-Funded              County-Funded              County-Funded Expense             County-Funded            % Variance
                                                     Budget                 Admin Expense             Program Expense               Total ( = Col. 2 + 3)              Budget                from Budget
A.PERSONNEL
  Salaries                                                                                                                                                0
  Taxes                                                                                                                                                   0
  Benefits                                                                                                                                                0
                        Subtotal A                                  0                        0                              0                             0                              0                  #DIV/0!
B.OPERATING
  Insurance                                                                                                                                               0
  Professional Fees                                                                                                                                       0
  Audit                                                                                                                                                   0
  Data Processing Fees                                                                                                                                    0
  Postage, Office, and Program Supplies                                                                                                                   0
  Equipment/Furnishings                                                                                                                                   0
  Depreciation                                                                                                                                            0
  Telephone                                                                                                                                               0
  Training/Conference                                                                                                                                     0
  Food/Household Supplies                                                                                                                                 0
  Auto Allowance                                                                                                                                          0
  Vehicle Costs                                                                                                                                           0
  Other1:                                                                                                                                                 0
  Other2:                                                                                                                                                 0
                        Subtotal B                                  0                        0                              0                             0                              0                  #DIV/0!
C.SPACE
  Rent                                                                                                                                                    0
  Utilities                                                                                                                                               0
  Maintenance                                                                                                                                             0
  Mortgage Interest, Depreciation,                                                                                                                        0
  Property Taxes                                                                                                                                          0
                        Subtotal C                                  0                        0                              0                             0                              0                  #DIV/0!
D.SPECIAL COSTS
  Assistance to Individuals                                                                                                                               0
                        Subtotal D                                  0                        0                              0                             0                              0                  #DIV/0!
E.OTHER
  Other3:                                                                                                                                                 0
  Other4:                                                                                                                                                 0
                        Subtotal E                                  0                        0                              0                             0                              0                  #DIV/0!
This section for Adult - DD only.
F. OFF-SETTING REVENUE
  Show as negative numbers:
  Government Benefits (SSI, SSDI, etc.)                                                                                                                    0
  Private Pay (Trust Funds, etc.)                                                                                                                          0
  Cost Share                                                                                                                                               0
  Other                                                                                                                                                    0
                        Subtotal F                       0                               0                                 0                               0                             0                  #DIV/0!
        TOTAL A THROUGH F                                0                               0                                 0                               0                             0                  #DIV/0!
                                   *CERTIFICATION: I certify the expenses listed above are true, correct, and allowable, in the amount stated and have not been reimbursed heretofore.
          bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 5 Exp Report                                                                                                                            Page 6 of 16
                                                          DANE COUNTY DEPARTMENT OF HUMAN SERVICES
                                                 EXPENSE REPORTS MUST BE PRESENTED USING THE ATTACHED FORMAT

                                                                                    Expense Report Instructions

                                      Provider
                                      Name            Enter legal name per current Dane County Contract Agreement.

                                      Program
                                      Name            Enter name of the program identified in your current Dane County Contract Agreement.

                                      Contract # Enter the current contract number.

                                      Program         Enter the current Program Group number provided by Dane County staff. It can be found on the
                                      Group #         Program Summary Form of the contract.

                                      Column 1        Approved County-Funded Budget. Use amounts from the County-funded column of the
                                                      approved (i.e., signed by both parties to the contract) program budget.

                                      Column 2        Year-to-Date County-Funded Admin Expense. Using the County’s definition of Admin, report
                                                      year-to-date County-funded Admin expenses in this column.

                                      Column 3        Year-to-Date County-Funded Program Expense. Using the County’s definition of Program,
                                                      report year-to-date County-funded Program expenses in this column.

                                      Column 4        Year-to-Date County-Funded Expense Total. This column is the sum of the expenses reported
                                                      in columns 2 and 3.

                                      Column 5        Year-to-Date County-Funded Budget. Assuming this is a 12-month program, divide column 1 by
                                                      12; then, multiply the result by the number of months that have elapsed in the contract period. For
                                                      example: If this is the expense report for May, the YTD budget column is determined by dividing
                                                      column 1 by 12 and multiplying by 5.

                                      Column 6        Year-to-Date % Variance from Budget. For each of the account categories (Personnel,
                                                      Operating, Space, Special Costs, Other, Off-setting Revenue), compute the percentage that year-to-
                                                      date expenses (Column 4) vary from the year-to-date budget (Column 5). Use one of the two
                                                      methods described below to find the percent. (Please round to two decimal places.) The Excel
                                                      Spreadsheet has this formula built in.

                                      Method I
                                      A.              Subtract year-to-date total expenses (Column 4) from year-to date budget (Column 5).

                                      B.              Divide this difference by the year-to-date budget (Column 5).

                                      C.              Multiply the result of Step B by 100 to give the percent variance from budget.

                                      Method II
                                      A.              Divide the year-to-date total expense (Column 4) by the year-to-date budget (Column 5).

                                      B.              Multiply the result by 100.

                                      C.              Subtract this result from 100. This is the percent variance from budget.




bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 6 Exp Report Instructions                                                                                        Page 7 of 16
                               DANE COUNTY DEPARTMENT OF HUMAN SERVICES
                                       EXPENSE REPORT DEADLINES:

                          Depending on whether the contract indicates
                          monthly or quarterly reporting, submit the
                                      Expense Report:                           by this date:
                               Monthly:              Quarterly:

                         January                                                       2/25/2011
                         February                                                      3/25/2011
                         March                           First Quarter                 4/25/2011
                         April                                                         5/25/2011
                         May                                                           6/25/2011
                         June                            Second Quarter                7/25/2011
                         July                                                          8/25/2011
                         August                                                        9/25/2011
                         September                       Third Quarter                10/25/2011
                         October                                                      11/25/2011
                         November                                                     12/25/2011
                         December                        Fourth Quarter                1/25/2012

                         Voucher Deadlines:

                         For programs paid in advance (method of payment #3 of the contract
                         Section C, XXV. B), vouchers are due on the first of the month prior to
                         the month the payment is to be issued.




bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 7 Paym&Exp Rep Deadlines                                Page 8 of 16
                  REVISION REQUEST FORM 2011                                                      DANE COUNTY DEPARTMENT OF HUMAN SERVICES
                          Contract Number:                                                                                          PROGRAM GROUP Number:
                                 AGENCY:                                                                                                   PROGRAM Name:

SECTION 1                                                               1             2                    3                 4             5                      6                   7              8              9                      10
                                                                                 Amount of
                  Account Category                         Current Budget        Adjustment       Requested Revision    % Variance      Current            Amount of        Revised       Admin   Current       Amount of        Revised        Program
                                                                                                                       (Col. 2/Col. 1
                                                            ( = Col. 5 + 8)     ( = Col. 6 + 9)     ( = Col. 7 + 10)      x 100)        Admin              Adjustment        ( = Col. 5 + 6)      Program       Adjustment         ( = Col. 8 + 9)
 A. PERSONNEL
    Salaries                                                                -                 -                   -                                                                         -                                                      -
    Taxes                                                                   -                 -                   -                                                                         -                                                      -
    Benefits                                                                -                 -                   -                                                                         -                                                      -
                                        Subtotal A:                         -                 -                   -       #DIV/0!                 -                     -                   -               -                -                     -
 B. OPERATING
    Insurance                                                               -                 -                   -                                                                         -                                                      -
    Professional Fees                                                       -                 -                   -                                                                         -                                                      -
    Audit                                                                   -                 -                   -                                                                         -                                                      -
    Data Processing                                                         -                 -                   -                                                                         -                                                      -
    Postage, Office, and Program Supplies                                   -                 -                   -                                                                         -                                                      -
    Equipment/Furnishings                                                   -                 -                   -                                                                         -                                                      -
    Depreciation                                                            -                 -                   -                                                                         -                                                      -
    Telephone                                                               -                 -                   -                                                                         -                                                      -
    Training/Conference                                                     -                 -                   -                                                                         -                                                      -
    Food/Household Supplies                                                 -                 -                   -                                                                         -                                                      -
    Auto Allowance                                                          -                 -                   -                                                                         -                                                      -
    Vehicle Costs                                                           -                 -                   -                                                                         -                                                      -
    Other1:                                                                 -                 -                   -                                                                         -                                                      -
    Other2:                                                                 -                 -                   -                                                                         -                                                      -
                                Subtotal B:                                 -                 -                   -       #DIV/0!                 -                     -                   -               -                -                     -
 C. SPACE
    Rent                                                                    -                 -                   -                                                                         -                                                      -
    Utilities                                                               -                 -                   -                                                                         -                                                      -
    Maintenance                                                             -                 -                   -                                                                         -                                                      -
    Mortgage Interest, Depreciation                                         -                 -                   -                                                                         -                                                      -
    Property Taxes                                                          -                 -                   -                                                                         -                                                      -
                                 Subtotal C:                                -                 -                   -       #DIV/0!                 -                     -                   -               -                -                     -
 D. SPECIAL COSTS
    Assistance to Individuals                                               -                 -                   -                                                                         -                                                      -
                                        Subtotal D:                         -                 -                   -       #DIV/0!                 -                     -                   -               -                -                     -
 E. OTHER
    Other3:                                                                 -                 -                   -                                                                         -                                                      -
    Other4:                                                                 -                 -                   -                                                                         -                                                      -
                                        Subtotal E:                         -                 -                   -       #DIV/0!                 -                     -                   -               -                -                     -
    This section for Adult - DD only.
 F. OFF-SETTING REVENUE
    Show as negative numbers:
    Government Benefits (SSI, SSDI, etc.)                                   -                 -                   -                                                                         -                                                      -
    Private Pay (Trust Funds, etc.)                                         -                 -                   -                                                                         -                                                      -
    Cost Share                                                              -                 -                   -                                                                         -                                                      -
    Other                                                                   -                 -                   -                                                                         -                                                      -
                                  Subtotal F:                               -                 -                   -       #DIV/0!                 -                     -                   -               -                -                     -
 G. TOTAL A through F                                                       -                 -                   -                               -                     -                   -               -                -                     -
                                                                                                                                               Admin % Variance                 #DIV/0!




        bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 8 Star 1000-1                                                                                                                                                                  Page 9 of 16
                                                                                      DANE COUNTY DEPARTMENT OF HUMAN SERVICES
            REVISION REQUEST FORM 2011
            Contract Number:                                                                                       PROGRAM Group Number:
                   AGENCY:                                                                                               PROGRAM Name:

SECTION 2
                                         1a            1                  2               3           4
                                                                                                   Revised            5              6          7         8           9
                                                                                                                                                                   Revised           10
                                                                                                                                                                                   Revised
                                        FTE         Current         Current Salary     Revised      Salary         Current        Revised    Current   Revised     Average         Average

   Staff Position/Category             Basis          FTE           ( = Col. 5 + 7)     FTE      ( = Col. 6 + 8)   Admin          Admin      Program   Program   Annual Salary Hourly Salary
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
                                          2080                 -                                            -                                                       #DIV/0!        #DIV/0!
TOTAL                                         0.000            -           0.000                            -             -              -         -         -
Salary totals in Section 2 must equal the amounts on the Salary lines in Section 1.                                Go to PAGE 2, Section 3




         bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 9 Star 1000-2                                                                                                         Page 10 of 16
      DANE COUNTY DEPARTMENT OF HUMAN SERVICES


                         AGENCY                                                                    PROGRAM NAME

                                                                    1                          2                      3
      SECTION 3                                                 Current                 Amount of            Requested Revision
                                                                Budget                  Adjustment              ( = Col. 1 + 2)
 H. Amounts from line G
      (Programs reimbursed according to Method of
      Payment C, use contract amount in column 1.)                                                                                0

      Allocate the amounts on Line H to the Standard Program Categories related to this program.
      (In each column, Line H = Line K + R + Y)

 I.     SPC Number:                                                                                                                   List Facility Numbers
 J.      SPC Name:                                                                                                                    related to this SPC:
 K. Dollars from Line H Allocated to this SPC                                                                                     0
 L. Number of Clients                                                                                                             0
 M. Number of Slots                                                                                                               0
 N. Unit Quantity                                                                                                                 0
 O. Unit Cost                                                   #DIV/0!                                            #DIV/0!

      STOP HERE UNLESS THERE IS MORE THAN ONE SPC FOR THIS PROGRAM.

 P. SPC Number:                                                                                                                       List Facility Numbers
 Q. SPC Name:                                                                                                                         related to this SPC:
 R. Dollars from Line H Allocated to this SPC                                                                                     0
 S. Number of Clients                                                                                                             0
 T. Number of Slots                                                                                                               0
 U. Unit Quantity                                                                                                                 0
 V. Unit Cost                                                   #DIV/0!                                            #DIV/0!


W. SPC Number:                                                                                                                        List Facility Numbers
X. SPC Name:                                                                                                                          related to this SPC:
 Y. Dollars from Line H Allocated to this SPC                                                                                     0
 Z. Number of Clients                                                                                                             0
AA. Number of Slots                                                                                                               0
AB. Unit Quantity                                                                                                                 0
AC. Unit Cost                                                   #DIV/0!                                            #DIV/0!

      The changes described above and on page 1 and 2 (Form *1000-1 and *1000-2) are approved.

      Provider:___________________________________________                         County:__________________________________________
      Date:______________________________________________                          Date:____________________________________________

      SECTION 4: INFORMATION ONLY




                                                 bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 10 Star 1000-3                                                    page 11 of 16
                                           DANE COUNTY DEPARTMENT OF HUMAN SERVICES
                                               Revision Request Instructions (DCDHS *1000)

      To simplify completing the forms, in the current columns (Current Budget, Current Salary, Current FTE, etc.) use
      figures from Program Budgets and Personnel Schedules that have been signed by both your agency and the County.
      If you have received an addendum, but have not had a revised budget form signed and returned to you, use the
      figures from your most recently approved Program Budget and Personnel Schedule in the current columns and
      include the changes in the requested revision columns.

      SECTION 1

      Column 1:               Current Budget. This is the current County-funded budget for this program. The amounts in this
                              column should come from your most recently approved (that is, signed by both your agency and
                              the County) Program Budget form.

      Column 2:               Amount of Adjustment. This column reflects the dollar change in each category. Unless you are
                              requesting a transfer of funds between programs or have had a change in the bottom line of your
                              contract since the budget in column 1 was approved, the total of this column should be -0-. (Note:
                              Distribute the amounts in this column to columns 6 and 9.)

      Column 3:               Requested Revision. Based on projected year-end expenditures, use this column to reflect how you
                              want your Dane County dollars distributed. (Note: Column 3 equals column 1 plus column 2.
                              You also need to distribute the amounts in column 3 to columns 7 and 10. And, the total of
                              column 3 for all programs should equal the amount of your contract.)

      Column 4:               % Variance. Show the percent variance for each category: Personnel, Operating, Space, Special
                              Costs, Off-setting Revenue, and Other. Calculate the Admin variance in the box at the bottom of
                              column 7.

      Columns 5-10: These columns represent the distribution of columns 1, 2, and 3 between administrative and
                    program costs. The amounts in the Current Admin (column 5) and Current Program (column 8)
                    columns should come from your most recently approved Program Budget form.

       SECTION 2

      Staff Position/
      Category        List each position by title.

      Column 1a:              FTE BASIS. For those agencies where 37.5 hours per week (1,950 hours per year) or some other
                              amount is considered full-time, please indicate the annual number of hours for 1 FTE in Column
                              1a by overwriting or crossing out the 2,080 (1 FTE for 40 hours per week) that is shown and
                              replacing it with your FTE basis. The FTE basis should be the same across all positions in an

      Column 1:               Current FTE. Use the number of FTEs from your most recently approved (that is, signed by both
                              your agency and the County) Personnel Schedule.

      Column 2:               Current Salary. Use the salary amount from your most recently approved Personnel Schedule. The
                              total of this column should equal the amount on the Salaries line in column 1, section 1.

      Column 3:               Revised FTE. Show the revised number of FTEs.

      Column 4:               Revised Salary. Show the revised salary amount budgeted for each position. Distribute the
                              amounts in this column to columns 6 and 8. The total of this column should equal the amount on
                              the Salaries line in column 3, section 1.



bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 11 Revision Req Instructions                                             Page 12 of 16
      SECTION 2 (Continued)

      Columns 5-8:            These columns represent the distribution of columns 2 and 4. The amounts in the Current Admin
                              (column 5) and Current Program (column 7) columns should come from your most recently
                              approved Personnel Schedule. The total of each of these columns should equal the amounts on the
                              corresponding Salaries lines in section 1.

      Columns 9-10: Column 9 displays the average annual salary, calculated by dividing the Salary shown in column 4
                    by the revised FTE shown in column 3. Column 10 shows the average hourly salary, calculated by
                    dividing the column 9 annual salary by the FTE basis hours shown in column 1a.

      SECTION 3
      The purpose of this section is to show the distribution of program expenses and client data to Standard
      Program Categories (SPC) as defined on the Program Summary Form of your contract.

      Most programs are identified with just one SPC. For those programs, you need only complete lines H
      through O. If a program has more than one SPC, however, you must distribute program costs to each SPC.
      The instructions given below for lines I through O can be applied to each SPC as necessary. (For those few
      providers with a program assigned more than three SPCs, please add additional pages.)

      Line H:                 Bring forward the amounts from line G in columns 1, 2, and 3, in Section 1. Note: If you are
                              completing this form for a program paid on the basis of units times unit rate, show the current
                              contract amount in column 1. Fill in columns 2 and 3 with the requested change in contract
                              dollars.

      Line I:                 Fill in the SPC number related to this program budget.

      Line J:                 Give the name for this SPC number.

      Fill in the facility numbers for this SPC in the boxes to the right of the double line.

      Column 1
      Line K:                 Show the dollars currently allocated to this SPC.
      Line L:                 Show the number of clients currently indicated to receive services in this SPC.
      Line M:                 Show the number of slots currently indicated in this SPC.
      Line N:                 Show the number of units currently indicated in this SPC.
      Line O:                 Show the current unit cost for this SPC.

      Column 2
      Line K:                 Show the amount of the adjustment allocable to this SPC.
      Line L:                 Show the change in the number of clients indicated in this SPC.
      Line M:                 Show the change in the number of slots indicated in this SPC.
      Line N:                 Show the change in the unit quantity for this SPC.
      Line O:                 Leave blank.

      Column 3
      Line K:                 Add columns 1 and 2.
      Line L:                 Add columns 1 and 2.
      Line M:                 Add columns 1 and 2.
      Line N:                 Add columns 1 and 2.
      Line O:                 Divide the amount on line K, column 3, by the units on line N, column 3.
      Sign and date the form on the lines provided.



bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 11 Revision Req Instructions                                              Page 13 of 16
                 ADMINISTRATION AND PROGRAM COST CLASSIFICATION GUIDELINES

ADMINISTRATION COSTS
Administration costs are costs related to the overall direction of the agency. These costs are often described as indirect costs.

Personnel
Salary, Tax & Benefit costs for personnel or contractors who carry out the following functions would generally be treated as
administrative costs.
 -Program evaluation
 -Program planning
 -Budget planning, tracking and development
 -Program and fiscal reporting
 -Management (Supervision of program managers, supervisors, accounting, human resource and administrative support staff)
 -Data and information technology system development and management
 -Data tracking and client record keeping
 -Sub-contracting, including contract negotiations and contract management
 -Accounting
 -Personnel Administration (human resource functions of staff recruiting and hiring)
 -Billing and third party collections
 -Agency-wide public relations
 -Brochure, web-site and publication development
 -Strategic planning
(Personnel who would be reported here could include executive directors, accountants, data processing staff, bookkeepers,
receptionists, business managers and administrative assistants. **)

Operating
 -Insurance
 -Professional Fees (100% of these costs would be reported as administration with the exception of program related professional
 -Agency audits
 -Postage, Office and Program Supplies
 -Equipment/Furnishings
 -Telephone
 -Training/Conference
 -Food/Household Supplies
 -Auto Allowance
 -Vehicle Costs
(Operating costs for administrative personnel, e.g., utilities, equipment, maintenance, legal services, purchasing.)

Space
-Space costs for administrative personnel

Other-Please specify




    bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 12 Adm & Pgm Guide                                                   Page 14 of 16
PROGRAM COSTS
Program costs are costs related to providing direct services or support within a specific program.

Personnel
 -Salary, Taxes and Benefit costs for personnel or contractors carrying out any of the following functions would be included in
program costs.
 -Direct client services (staff who provide 90 percent or more of their time carrying out these functions are considered 100 percent
program cost)
 -Face-to-face client or phone contact
 -Client-specific advocacy needed to obtain services for individual clients
 -Supervisory time spent on directly supervising individuals who are responsible for direct client services, when that supervisory
time is focused on the work that staff do with clients.
(Personnel who would be reported here could include program managers, program support staff, supervisors and line staff. **)

Operating
 -Insurance
 -Professional Fees/ (Only program related professional fees.)
 -Postage, Office and Program Supplies
 -Equipment/Furnishings
 -Telephone
 -Training/Conference
 -Food/Household Supplies
 -Auto Allowance
 -Vehicle Costs
(Operating costs for program personnel, insurance, utilities, equipment, maintenance, legal services, purchasing, professional fees,
postage, supplies, telephone, food/household supplies, auto allowance, vehicle costs.)

Space
-Space costs for program personnel

Special Costs-Assistance to Individuals

Other-Please specify

If these guidelines do not completely address or clarify your unique set of circumstances, questions regarding the County’s
interpretation of proper classification between program and administrative cost classifications should be directed to your contract
manager who will work with our fiscal staff to resolve your questions.

**It is possible that some positions may have duties that are classified as Administration and duties that are classified as Program.
If this is the case, the costs should be allocated in a reasonable manner between the administration and program categories.




    bca1206e-acba-4fe3-b551-c2d3347824ba.xls - 12 Adm & Pgm Guide                                                  Page 15 of 16
                                           DANE COUNTY DEPARTMENT OF HUMAN SERVICES
                                              BUDGET LINE ITEM EXPENSE GUIDELINES


             PERSONNEL
                                           Direct salaries and wages for all staff whose work is specifically tied to the program, along with the
                                           allocation of salaries and wages for all staff performing functions that are necessary and beneficial to all
Salaries                                   programs.
Taxes                                      FICA.
                                           Pension or Retirement plans, Health, Dental, Vision, Life, Disability, Unemployment, and Workers
Benefits                                   Compensation insurance.


               OPERATING
                                           Property, Liability, Umbrella, Hazard, Terrorism, Auto, Director's & Officer's, Employee Theft &
Insurance                                  Dishonesty.

                                           Consultants, sub-contractors, and contract services. Includes legal, accounting, educational, psychiatric or
Professional Fees                          psychological, medical, employment, information technology (IT), or management services.
Audit                                      Agency audit costs.
Data Processing                            Data processing costs.
                                           Postage, photocopy, program, and office supplies including pens, pencils, paper, staples, paperclips,
Postage, Office, and Program Supplies      folders, tape, clips, etc.
Equipment/Furnishings                      Costs related to tables, desks, computers, software, telephones, copiers, fax, etc.
Depreciation                               Depreciation expense related to equipment & furnishings.
Telephone                                  Telephone, pager, fax and internet charges
Training/Conference                        Training/conference charges.
                                           Client related food/household supply costs including toilet paper, paper towels, cleaning supplies, food
Food/Household Supplies                    used by daycare providers, food for provision of on-site meals, etc.
Auto Allowance                             Employee and volunteer mileage reimbursement costs.
Vehicle Costs                              Vehicle lease costs, gas, maintenance and repair of vehicles.
                                           Miscellaneous goods and services not identified; other costs may include: interpreter services, AODA tests,
Other1:                                    employer support, recruitment, background checks, etc.
Other2:

                  SPACE
Rent                                       Rent/lease costs.
Utilities                                  Electricity, gas, heat, sewer & water costs.
                                           Maintenance costs including janitorial supplies/services, building repairs, grounds keeping, snow removal,
Maintenance                                etc.
Mortgage Interest, Depreciation            Mortgage interest & building related depreciation costs.
Property Taxes                             Property tax costs.


            SPECIAL COSTS
                                           Direct client assistance including, but not limited to, rent, security deposit, application fee, utilities, gas
                                           vouchers, bus tickets, food, prescription, dental or medical co-pays and equipment, tools, childcare, birth
Assistance to Individuals                  certificates, and id's.


            OTHER (Specify)
Other3:                                    Other costs including membership dues, licenses, fees, subscriptions, etc.
Other4:                                    Other costs including membership dues, licenses, fees, subscriptions, etc.


      OFF-SETTING REVENUE                                        This section is for Adult - Developmental Disabilities (DD) only.
Show as negative numbers:
Government Benefits (SSI, SSDI, etc.)
Private Pay (Trust Funds, etc.)
Cost Share
Other


                            Revised 3/09
                                                                                                                                             Page 16 of 16

								
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