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FY12_HTGYM_Instructions.doc - Family Connection Partnership

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									Fiscal Year 2012 Reports
User’s Guide (9/11)                                    Page 1 of 26




           FY 2012
      Required Financial
           Reports:
         Instructions


                  (How to Get Your Money)


                           July 2011
                             (9/11)




                                       Resource Development and
                                       Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                      Page 2 of 26



                                        Table of Contents
                           FY 2012 Required Financial Reports: Instructions
                                     (How to Get Your Money)
                                                                                      Page

INTRODUCTION                                                                              3

GENERAL REQUIREMENTS                                                                      4

DHS DEADLINES FOR REQUIRED REPORTS                                                        4

QUARTERLY REPORTING FORMS                                                                 5

Annex B – Part 1, “Contract Budget and Quarterly Expenditure Report FY12”                 6

Annex B – Part 2, “Quarterly Subcontractor Report”                                        7

Annex C – Part 1, “Quarterly Narrative Report”                                            8

Annex C – Part 2, “Status Report, FY 2012 Plan of Action (if Required)”                   8

DHS Form 5111 “Detailed Equipment Listing”                                                8

BUDGET REVISIONS (including sample of CIMS letter)                                    9 -11

SUBMISSION CHECKLIST                                                                    12
     1st quarter                                                                        12
     2nd quarter                                                                        12
     3rd quarter                                                                        12
     4th quarter                                                                        12

UNANTICIPATED GRANT REDUCTIONS                                                          13

RECORD RETENTION REQUIREMENTS                                                           13

AUDIT REPORTING BY FISCAL AGENT TYPE                                                  14-15

CRITICAL INCIDENCE REPORT                                                             16-17

Samples of CIMS Forms: Annex B, Parts 1 and 2; Annex C, Parts 1 and 2                 18-22

Example: Family Connection Budget Revision Request                                      23

DHS BUDGET PREPARATION ALLOWABLE COSTS                                                24-25

Health/Medicaid Collaborative & Collaborative Partner Activity Categories               26



                                                                        Resource Development and
                                                                        Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                          Page 3 of 26


INTRODUCTION
This document contains information and descriptions of Georgia Family Connection financial
reports required for the reimbursement of state Family Connection grant funds: Annexes B and
Annexes C. It includes a description of each part of Annexes B and C; the general requirements for
completing the reporting forms; the deadlines for each quarterly reporting form, and example
copies of the CIMS forms. These reports must be completed by all collaboratives and their fiscal
agents—including those collaborative’s for whom the Department of Family and Children Services
(DFCS) serves as the fiscal agent, even though DFCS does not receive a contract but instead
receives their funding through grant-in-aid (GIA). The quarterly reports must be entered into the
Web-based reporting system known as the Collaborative Information Management System (CIMS)
and printed from the system prior to the signing and mailing for reimbursement. Also, this
document summarizes information often needed by the collaborative and their fiscal agent.

These reporting forms are developed only on CIMS. Samples of these forms and other financial
tools, are also available on the Georgia Family Connection Partnership’s Web site. Go to
www.gafcp.org.

If you have any questions please call the Georgia Family Connection Partnership Contract
Manager at 404. 527.7394.

Financial Reports – Annex B
Annex B contains the expenditure reports for the grant. This annex has two parts.

Annex B Part 1 is titled “Contract Budget and Quarterly Expenditure Report FY 12” and serves two
functions (entered in and printed from CIMS):
    It is the contract expenditure report, used as the request for reimbursement
    It is the budget revision report, used to request a change in the budget line items.

Annex B Part 2 is the “Family Connection State Grant Quarterly Subcontractor Report”. This report
itemizes the quarterly expenditures in the category for Per Diem, Fees and Contracts (line item F in
the Family Connection Approved Budget shown on Annex B Part 1).

Programmatic Reports – Annex C
Annex C is a report on the collaborative’s activities for the quarter. Annex C has two parts:

        Annex C Part 1, “Family Connection Quarterly Narrative Report.” This is a summary report
         on the collaborative’s programmatic progress during the quarter. It is often referred to as
         the Quarterly Programmatic Narrative Report. It includes information on the collaborative’s
         and collaborative partners’ activities and programs focused on health outreach during the
         quarter.
        Annex C Part 2, “Family Connection Status Report, FY 2012 Plan of Action.” This
         document verifies that any required action plan are on track. This form is an additional first
         quarter reporting requirement for some counties who have received a letter from the
         Georgia Family Connection Partnership office requiring a plan of action for the Strategic
         Plan, Annual Plan, and/or Standards.




                                                                       Resource Development and
                                                                       Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                        Page 4 of 26


GENERAL REQUIREMENTS
The Department of Human Services (DHS), is the fiscal agent for the Georgia Family Connection
legislative appropriation for county collaboratives. The completion and printing from CIMS along
with submission of these annexes is required for reimbursement from DHS. This is true whether
the fiscal agent is a governmental agency, a not-for-profit corporation, or DFCS (who does not
receive the money through a contract, but receives it instead through their regular grant-in-aid
(GIA) allocation).

DHS contracts are written for one year, beginning July 1, 2011 and ending June 30, 2012. No
contracts can be extended beyond the June 30, 2012 end date. All reports are prepared on
CIMS and submitted with original signatures—no faxed copies can be accepted. Reports
must be reviewed and approved in the Georgia Family Connection Partnership office before they
are submitted to DHS.

DHS DEADLINES FOR REQUIRED REPORTS
Deadlines for report submittal are part of the contract and grant requirements for all fiscal agents—
including DFCS. It is important to meet these deadlines, as they are a contractual and grant
responsibility. Failure to comply could result in delay of payment, contract or GIA suspension, or in
worst case, contract termination.

All counties have the same due dates. This is true for counties who receive their funding through a
regular contract, and counties where DFCS serves as the fiscal agent and the collaborative
receives its funding through grant-in-aid. The reporting quarters, the reports required, and the due
dates for both counties with contracts and counties where DFCS serves as the fiscal agent are:

1st quarter (July, August, September)
          o Annex B Part 1, “Contract Budget and Quarterly Expenditure Report FY12”
          o Annex B Part 2, “Quarterly Subcontractor Report” (if required)
          o Annex C Part 1, “Quarterly Narrative Report”
          o Annex C Part 2, “FY 2012 Plan of Action” (if required)
          o DHS Form 5111 “Detailed Equipment Listing” (if required)

             Due Dates: October 17, 2011


2nd quarter (October, November, December)
          o Annex B Part 1, “Contract Budget and Quarterly Expenditure Report FY12“
          o Annex B Part 2, “Quarterly Subcontractor Report” (if required)
          o Annex C Part 1, “Quarterly Narrative Report”
          o Annex C Part 2, “FY 2012 Plan of Action” (if required)
          o DHS Form 5111 “Detailed Equipment Listing” (if required)

             Due Dates: January 17, 2012




                                                                     Resource Development and
                                                                     Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                        Page 5 of 26


3rd quarter (January, February, March)
          o Annex B Part 1, “Contract Budget and Quarterly Expenditure Report FY12”
          o Annex B Part 1, contract budget revision, if needed. See section below on Budget
              Revisions. All budget revisions needed before the end of the fiscal year must be
              entered and printed from CIMS by April 20, 2012, signed, and received in the
              Georgia Family Connection Partnership Office prior to May 1, 2012.
          o Annex B Part 2, “Quarterly Subcontractor Report”
          o Annex C Part 1, “Quarterly Narrative Report”
          o Annex C Part 2, “FY 2012 Plan of Action” (if required)
          o DHS Form 5111 “Detailed Equipment Listing” (if required)

             Due Dates: April 16, 2012

4th quarter (April, May, June)
          o Annex B Part 1, “Contract Budget and Quarterly Expenditure Report FY12”
          o Annex B Part 1, contract budget revision, if needed. See section below on Budget
              Revisions. All budget revisions needed before the end of the fiscal year must be
              entered and printed from CIMS by April 20, 2012, signed, and received in the
              Georgia Family Connection Partnership Office prior to May 1, 2012.
          o Annex B Part 2, “Quarterly Subcontractor Report” (if required)
          o Annex C Part 1, “Quarterly Narrative Report”
          o Annex C Part 2, “FY 2012 Plan of Action” (if required)
          o DHS Form 5111 “Detailed Equipment Listing” (if required)

             Due Dates: August 15, 2012

NOTE: The final date to enter a budget revision into CIMS is April 20, 2012.

Please make every effort to submit the quarterly reports as soon as possible following the last day
of the quarter, in order to not delay the fiscal agent’s payments. Your fiscal agent will appreciate
your attention to this matter. Expenditure reports cannot be entered into CIMS or accepted prior to
the end of the quarter; however, entering information for the quarterly narrative report can begin
prior to that time.

Mail all signed CIMS forms to:
         Contract Manager
         Georgia Family Connection Partnership
         235 Peachtree Street – Suite 1600
         Atlanta, GA 30303-1422

QUARTERLY REPORTING FORMS
There are up to five (5) reporting forms that may be required during the course of the year for the
collaborative to receive its legislative allocation. These include Annex B Parts 1 and 2; Annex C
Parts 1 and 2; and the DHS equipment listing form.

Not all forms are required for every collaborative.

These reports must be completed by all collaboratives and their fiscal agents—including those
collaborative’s for whom the Department of Family and Children Services (DFCS) serves as the

                                                                     Resource Development and
                                                                     Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                               Page 6 of 26
fiscal agent—even though DFCS does not receive a contract but instead receives their funding
through grant-in-aid (GIA).

All reporting forms should be mailed to
        Contract Manager
        Georgia Family Connection Partnership
        235 Peachtree Street – Suite 1600
        Atlanta, GA 30303-1422

Annex B Part 1, “Contract Budget and Quarterly Expenditure Report FY12” is a form that
serves one function:
    It is the contract expenditure report, that is, the request for reimbursement

Annex B Part 1 example is attached to the contract, or if DFCS is the fiscal agent, it is included in
the material mailed to DFCS by the Georgia Family Connection Partnership office. This Annex is:
     Required quarterly and must be prepared and printed using CIMS
     Must be signed by the collaborative chairperson and the fiscal agent representative
     Must be dated
     Must be submitted with original signatures, not faxed
     Must be submitted at the same time as Annex C Part 1, and (if required) the Annex B Part
       2, “Quarterly Subcontractor Report”
     Required for all reimbursements

Using CIMS, indicate the appropriate quarter—1, 2, 3, or 4—for which you are reporting. The
contract number for the FY12 contract will already be entered in CIMS. Please ensure it is the
correct contract number. If DFCS is the fiscal agent, “GIA” will be shown in the contract # blank.

Completing the form on CIMS
      Column 1, “Family Connection Approved Budget.” This column reflects the collaborative’s
      approved budget for FY 2012.

         Column 2, “Expenditures for Reimbursement Quarter #___.” Record the total expenditures
         for each budget category during the current quarter for which you are requesting
         reimbursement. At the top of the column enter the appropriate quarter number. CIMS will
         make sure all columns are totaled correctly.

         Column 3, “Prior Cumulative Expenditures.” This column reflects the total amount that has
         been expended for each budget category prior to this quarter. The current quarter’s
         expenditure is not included in the total. (This column will be zero for the first quarter report.)

         Column 4, “Total Year to Date Expenditures.” This column reflects the amounts shown in
         the column “Expenditures for Reimbursement Quarter # __” (column 2) and plus the
         amount shown in the column “Prior Cumulative Expenditures” (column 3). In other words,
         column 2 + column 3 = column 4.

         Column 5, “Budget Remainder.” This column reflects the difference between column 1,
         “Family Connection Approved Budget” and column 4, “Total Year to Date Expenditures”.
         (column 1 –column 4 = column 5)
    Note:Ensure that the amounts entered into CIMS agree with the official records of your fiscal agent
    for the quarter reported.
                                                                           Resource Development and
                                                                           Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                       Page 7 of 26


Annex B Part 2, “Quarterly Subcontractor Report” is prepared and printed from CIMS and
itemizes for each contract and service the quarterly expenditures in the category for Per Diem,
Fees and Contracts (line item F in the approved Budget on Annex B Part 1). It must agree with the
fiscal agent’s official accounting records. A sample form is attached to the contract, or if DFCS is
the fiscal agent, the sample is included in the material mailed to DFCS by the Georgia Family
Connection Partnership office. This annex:
     Applies only to counties with funds allocated and expenditures listed in line item “F, Per
        Diem, Fees and Contracts,” of the Family Connection Approved Contract Budget
     Must be prepared and printed using the Web based reporting system (CIMS)
     Submitted quarterly (if applicable)
     All columns must be filled out for each contractor
     Must be signed by the Fiscal Agent
     Must be dated
     Must include name and information for all contracts, leases, and other services expensed in
        this budget line item category

The report documents for DHS the name of each subcontractor under the Family Connection
contract, the services provided, the subcontract amount in dollars, the quarterly amount expensed
for each contractor, and the report verifies whether the subcontractor is a small or minority
business (note that the purchase of equipment for the subcontractor is not allowable).

A “Small Business” is defined as an independently owned and operated entity that has either fewer
than one hundred (100) employees or less than one million ($1,000,000) in gross receipts per year.
A “Minority Owned Business” means a business that is 51% owned or controlled by one or more
minority persons, e.g. African American, Hispanic/Latino, Native American, Asian American, and
Pacific Islander. (State Statute 50-5-121).

DHS requires the total amount of the subcontract for the year be shown on the report. By
government accounting standards, the total amount of a subcontract is viewed as encumbered
even though not yet expended.

For questions related to the report please contact Contract Manager at 404.527.7394. And
remember that all reports must be prepared and printed using CIMS.

Mail the signed Annex B (CIMS) forms to:
        Contract Manager
        Georgia Family Connection Partnership
        235 Peachtree Street – Suite 1600
        Atlanta, GA 30303-1422


    Note: Keepcopies of all signed Annex B quarterly reports and printed
    CIMS copies of Annex C forms for the fiscal agent and collaborative’s
    FY12 contract files or DFCS GIA files.




                                                                    Resource Development and
                                                                    Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                        Page 8 of 26


Annex C
Annex C is a report on the collaborative’s activities for the quarter. There are two parts to Annex
C:
    Annex C Part 1, “Family Connection Quarterly Narrative Report” is a report on the
      collaborative’s progress during the quarter
    Annex C Part 2, “Status Report FY 2012 Plan of Action”, if required

Annex C Part 1, “Family Connection Quarterly Narrative Report”
This report is a program narrative, rather than a budget narrative:
    Required quarterly
    Entered into CIMS when Annex B Part 1 “Contract Budget, and Quarterly Expenditure
       Report FY 12” is prepared
    Required for all reimbursement
    Must be entered into CIMS in order for expenditure reimbursement to be paid
    Includes collaborative’s and collaborative partners’ health and Medicaid activities during
       quarter
    See submission checklist for submittal dates and accompanying reports
    Print a copy of the report for the fiscal agent and collaborative’s contract – GIA FY12 official
       file.


Annex C Part 2, “Status Report, FY 2012 Plan of Action”
This document verifies that the required “Plan of Action” for the quarter has been completed, and
information identified in the plan has been submitted to the Georgia Family Connection Partnership
(GaFCP) office.

This form:
    Applies only to counties receiving a “Plan of Action” notice
    If required, must be processed with quarterly reports
    Note on your contract files the date that it was reviewed and approved by your regional
        GaFCP Community Facilitator (CF)
    If required, must be approved to receive quarterly reimbursement
    GaFCP Community Facilitator (CF) reviews Plan of Action status with collaborative and
        coordinates Annex C Part 2 approval with GaFCP Team Director for the director’s signature



DHS Form 5111 “DETAILED EQUIPMENT LISTING”
This form applies only to counties whose Annex B Part 1 for the FY 2012 contract reflects
equipment budgeted under budget line item D, Equipment (Items costing $1,000 or more).

The fiscal agent is responsible for the equipment purchased and for preparing inventory forms. No
collaborative has equipment costing more than $1,000 in their approved FY12 grant budget. If the
collaborative revises the grant budget to include equipment funding, DHS contract Paragraph #107
Contract Modification/Alteration, Section A are followed. DHS must approve the addition of the
item prior to state approval of the budget revision and purchase of identified equipment.



                                                                     Resource Development and
                                                                     Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                         Page 9 of 26
DHS Form 5111 “DETAILED EQUIPMENT LISTING” (cont.)
DHS Form 5111 “DETAILED EQUIPMENT LISTING” is a multi-part form, with a white original, and
pink, yellow, and blue ‘carbons.” The instructions for completing the form are found on the back of
the form’s final page.

For reimbursement, a copy of the completed form, with a copy of the purchase order(s), must be
attached to the quarterly expenditure report, Annex B – Part 1, which shows equipment has been
purchased.

The amount shown on this form must be identical to the amount shown on Annex B Part 1 line item
D Equipment. If the two figures do not agree, reimbursement for equipment will be withheld.

If there is any equipment purchased during the quarter under line item D, Equipment, contact the
Georgia Family Connection Partnership Contract Manager to request a copy of this form.

For any questions related to completing the form contact Contract Manager at 404.527.7394.

The completed original form (with all copies intact—white sheet, pink sheet, yellow sheet, blue
sheet) and the purchase order are to be attached to Annex B Part 1 if equipment was purchased,
and sent to:

         Contract Manager
         Georgia Family Connection Partnership
         235 Peachtree Street – Suite 1600
         Atlanta, GA 30303-1422

State of Georgia, bar code decals will be sent to the fiscal agent by DHS to be affixed to each
piece of equipment purchased with grant funds and reported in line item D on the expenditure
report.


BUDGET REVISIONS
CIMS is used for all Budget Revisions for the Family Connection state grant. Follow the
instructions provided on CIMS. If you encounter problems with CIMS, send an email to
cims@gafcp.org. Budget Revisions are not required. They are only used when a collaborative
budget requires major revision, such as when a vacancy occurs due to change in coordinators.

All fiscal agents for collaboratives, including DFCS, must submit a budget revision if there is a
change in any line item.

When considering budget revisions, keep in mind the following:
       The contract grant allows a 20% by line variance. This means you can over-spend or
         under-spend any line item(s) up to 20% without revising the budget, but you are not
         allowed to over-expend the total contract amount.
       Budget revisions are necessary only when moving funds from one line item or category
         to another line item or category.
       Revision of the budget exceeding the 20% line variance must be made and approved
         by GaFCP, in writing, prior to expending the funds.
       Keep in mind any revision of budget must be for activities or programs that were
         included in the Annual Plan for the current year.
                                                                      Resource Development and
                                                                      Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                      Page 10 of 26
BUDGET REVISIONS (cont.)
            Only whole dollars are used in the budget and/or revision of the budget.
            Make sure proposed expenditures are allowable and are being placed in the proper line
             item by checking the DHS Budget Preparation Allowable Costs sheet.
            The collaborative must approve the budget revision request prior to submission to the
             Georgia Family Connection Partnership office.
            No funds can be expended prior to approval of the budget revision from the Georgia
             Family Connection Partnership office.

Preparing the Budget Revision
    Enter the budget revision information following the instructions on CIMS prior to April 20,
       2012 (last date to enter budget revision into CIMS).
    Print the budget revision form from CIMS (An example of the form is found in the Sample
       Forms Section of this guide on page 24).
    Next, have the collaborative chair and fiscal agent representative sign and date the form.
    Finally, hold a board meeting at which the collaborative board will vote and approve the
       revised budget.

Following board approval, complete the letter to Contract Manager at the Georgia Family
Connection Partnership office (prepared using CIMS). This letter must:
     Be signed
     Note the date the board met and approved the budget revision (include action in meeting
       minutes)
     State the board approved the budget revision request
     Note every line item/budget category changed, and the amount of increase or decrease
     Provide a brief explanation or description of the change and why the change was necessary
       and requested

Make a copy of the letter and the budget revision form for the collaborative and fiscal agent’s FY12
contract files after board approval.

A sample of CIMS letter follows.

Remember, under no circumstances can you exceed the total current contract amount of $44,000
(grant amount as of July 2011) nor can you spend funds prior to approval by the state of the
budget revision request.

The deadline for entering data into CIMS for final budget revisions is April 20, 2012.
Any signed budget revision received by the Georgia Family Connection Partnership office
after the April 30 receipt deadline will not be considered for approval.

Submit the approved, signed, revised CIMS budget revision and letter for review and approval to:

         Contract Manager
         Georgia Family Connection Partnership
         235 Peachtree Street – Suite 1600
         Atlanta, GA 30303-1422



                                                                    Resource Development and
                                                                    Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                          Page 11 of 26




                                SAMPLE of CIMS letter
                REVISION OF FAMILY CONNECTION STATE GRANT BUDGET



Date: March 10, 2012



To:      Contract Manager
         Georgia Family Connection Partnership
         235 Peachtree Street NW, Suite 1600
         Atlanta, GA 30303-1422

From: WeCare County Collaborative

Subject:
       Budget Revision No. 1
       Contract No. 427-93-121200XXX-99
       Fiscal Agent Name: WeCare Board of Education
       County Name: WeCare County Collaborative

The WeCare County Collaborative requests the following budget revisions:

         Line Item A. Personal Services--Decrease Personal Services from $39,250 to $36,567 for
         a total decrease of $2,683 because the position has been vacant for one month.

         Line Item B. Regular Operating—Increase Regular Operating from $2,853 to $5,536 for a
         total increase of $2,683 to allow for the collaborative to print a new collaborative resource
         directory and to cover the rise in cost of Directors and Officers (D&O) insurance.

The WeCare County Collaborative board met on March 1, 2012 and approved these budget
revisions and they are duly recorded in the minutes of that meeting.

If you have any questions please contact Ms. Ima Smartee, WeCare County Coordinator, at the
following telephone number 820.555.1212, or email her at imasmartee@wecareco.org.




(Also refer to Example of Family Connection Budget Revision at end of this document in “II.Other”)




                                                                      Resource Development and
                                                                      Contract Management Team
 Fiscal Year 2012 Reports
 User’s Guide (9/11)                                                                           Page 12 of 26


                                    SUBMISSION CHECKLIST

                  1st Quarter (July, August, September) Due Dates: October 17, 2011
     _____    Annex B Part 1, “Contract Budget and Quarterly Expenditure Report FY12”
     _____    Annex B Part 2, “Quarterly Subcontractor Report” (if required)
     _____    Annex C Part 1, “Quarterly Narrative Report”
     _____    Annex C Part 2, “FY 2012 Plan of Action”,(if required)
     _____    DHS Form 51111 “Detailed Equipment Listing” (if required)
     _____    Copies made for county files


                2nd Quarter (October, November, December) Due Dates: Jan. 17, 2012
     _____    Annex B Part 1, “Contract Budget and Quarterly Expenditure Report FY12
     _____    Annex B Part 2, “Quarterly Subcontractor Report” (if required)
     _____    Annex C Part 1, “Quarterly Narrative Report”
     _____    Annex C Part 2, “FY 2012 Plan of Action”,(if required)
     _____    DHS Form 51111 “Detailed Equipment Listing” (if required)
     _____    Copies made for county files


             3rd quarter (January, February, March) Due Dates : April 16, 2012
     _____ Annex B Part 1, “Contract Budget and Quarterly Expenditure Report FY12”
     _____ Annex B Part 1, Contract Budget Revision, if needed (CIMS Deadline: April 20, 2012)
     _____ Annex B Part 2, “Quarterly Subcontractor Report” (if required)
     _____ Annex C Part 1, “Quarterly Narrative Report”
     _____ Annex C Part 2, “FY 2012 Plan of Action”,(if required)
     _____ DHS Form 51111 “Detailed Equipment Listing” (if required)
     _____ Copies made for county files
     NOTE: the third quarter is the last opportunity for budget revisions


                       4th quarter (April, May, June) Due Dates: August 15, 2012
_____   Annex B Part 1, “Contract Budget and Quarterly Expenditure Report FY12”
_____   Annex B Part 1, Contract Budget Revision, if needed (CIMS Deadline: April 20, 2012)
_____   Annex B Part 2, “Quarterly Subcontractor Report” (if required)
_____   Annex C Part 1, “Quarterly Narrative Report”
_____   Annex C Part 2, “FY 2012 Plan of Action”,(if required)
_____   DHS Form 51111 “Detailed Equipment Listing” (if required)
_____   Copies made for county files


 For additional information call the Contract Manager at 404.527.7394.

 Mail all required annexes with attached reports and original signatures to:
 Contract Manager
 Georgia Family Connection Partnership
 235 Peachtree Street – Suite 1600
 Atlanta, GA 30303-1422


                                                                               Resource Development and
                                                                               Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                                Page 13 of 26


UNANTICIPATED GRANT REDUCTIONS
In the event that the FY12 Family Connection grant is reduced by the Legislature and Governor
due to the decline in tax revenue collections; the collaborative chair, fiscal agent and coordinator
will be notified immediately by email from the Georgia Family Connection Partnership.

Collaboratives whose fiscal agents have a contract will receive notification of the contract
amendment per contract:

    PARA #107 CONTRACT MODIFICATION/ALTERATION
    B. In the event that either of the sources of reimbursement for services under this contract
       (appropriations from the General Assembly of the State of Georgia, or the Congress of the United
       States of America) are reduced during the term of this contract, the Department has the absolute
       right to make financial and other adjustments to this contract and to notify the Contractor accordingly.
       Such adjustment(s) may require a contract amendment including, but not limited to, a termination of
       the contract. The certification by the Commissioner of the Department of the occurrence of either of
       the reductions stated above shall be conclusive.

Collaboratives with DFCS serving as the Family Connection fiscal agent will be notified of the grant
reduction when the state DFCS budget office receives instructions to reduce the grant amount. A
copy of the grant reduction correspondence will be mailed to the chair, local DFCS fiscal agent and
coordinator.

No budget revision is required in CIMS to reflect any such grant reduction. The only action
required by the collaborative is to reduce spending to ensure the new grant amount is not over-
spent. Total reimbursement of the contract will not exceed the new grant amount. Contact the
Georgia Family Connection Partnership contract manager if there are questions.

RECORD RETENTION REQUIREMENTS
In the contract signed by the collaborative’s Fiscal Agent with the Georgia Department of Human
Services, records retention requirements are in the paragraph related to access to records and
investigation. The limit is seven years--and in case of litigation, may be more. And basically
everyone has to keep everything. The contract paragraph is reproduced below. It is found on
page 4 of the FY 2012 contract.

         PARA #113 ACCESS TO RECORDS AND INVESTIGATION
         A. The state and federal government and the Department shall have full and complete access to all
            consumer/customer/client records, administrative records, financial records, pertinent books,
            documents, papers, correspondence, including e-mails, management reports, memoranda, and
            any other records of the Contractor and subcontractor for the purpose of conducting or reviewing
            audit examinations, excerpts, and transcripts. Contractor and subcontractor record retention
            requirements are seven years from submission of final expenditure report. If any litigation, claim,
            or audit is started before the expiration of the six-year period, the records shall be retained until
            all litigations, claims, or audit findings involving the records have been resolved.

Collaboratives with DFCS serving as their fiscal agent should follow the above guidance.

Targeted Case Management (TCM) Documents Retention
If in the past, your collaborative EVER participated in the Family Connection “Children At-Risk
Targeted Case Management” (TCM) program with Medicaid, then:

TCM record retention is: all case files and notes must be retained for seven years. These records
include the client’s signed consent form; Individual Service Plan, updated and signed as
                                                                             Resource Development and
                                                                             Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                                Page 14 of 26
periodically required; Brief Follow-up notes and records; and Extended Follow-up notes and
records. The case file should contain notes and records of all client contact.


AUDIT REPORTING BY FISCAL AGENT TYPE
The Department of Human Services Contract audit requirements by contractor type are referenced
in Paragraph 402 of the FY12 Contract. Following is the information by fiscal agent type.

Boards of Education:
Contractor agrees to provide within nine (9) months after the close of the Contractor’s fiscal year, two (2)
copies of the audit report conducted by the State Department of Audits and Accounts or by an independent
Certified Public Accountant approved by the State Department of Audits and Accounts to:
         Georgia Department of Audits and Accounts
         Education Audit Division
         270 Washington Street, S.W.
         Atlanta, Georgia 30334-8400

Local Governments:
Contractor agrees to provide within 180 days after the close of the Contractor’s fiscal year, two (2) copies of
the audit or annual report required of local governments by Section 36-81-7 of the Official Code of Georgia
and two (2) copies of the additional reports, statements, schedules and forms outlined in the Department of
Human Services On-line Directives information System POL 1244, External Entities Audit Standards and
Sanctions, to:
        Georgia Department of Audits and Accounts
        Nonprofit and Local Government Audits Division
        270 Washington Street, S.W.
        Atlanta, Georgia 30334-8400

Private Non-Profits:
Contractors that expend $500,000 or more in Federal funds during their fiscal year agree to have a single
entity-wide audit conducted for that year in accordance with the provisions of the single Audit Act
Amendments of 1996 (Public Law 104-156) and their implementing regulation, OMB Circular A-133 entitled,
“Audits of States, Local Governments, and Nonprofit Organizations.” The audit reporting package shall
include the documents listed in Policy 1244 of the DHS Directives Information System.

Contractors expending $100,000 or more in State funds during their fiscal year agree to have an entity-
wide audit conducted for that year in accordance with Generally Accepted Auditing Standards issued by the
American Institute of Certified Public Accountants. The audit reporting package shall include the documents
listed in Policy 1244 of the DHS Directives Information System.

Contractors expending at least $25,000 but less than $100,000 in State funds during their fiscal year agree
to prepare unaudited entity-wide financial statements for that year. Assertions concerning the basis of
financial statement preparation must be made by the president or other corporate official as described in
Policy 1244 of the DHS Directives Information System.

Contractor further agrees to submit the required audit or financial statements in the quantities set forth below,
within 180 days after the close of the Contractor’s fiscal year:

Two (2) copies to:                                One (1) copy to:
Office of Inspector General                       Georgia Department of Audits and Accounts
Internal Audit Unit                               Nonprofit and Local Government Audits Division
Room #26-425                                      270 Washington Street, S.W.
Two Peachtree Street, N.W.                        Atlanta, Georgia 30334-8400
Atlanta, Georgia 30303-3142



                                                                             Resource Development and
                                                                             Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                               Page 15 of 26

AUDIT REPORTING BY FISCAL AGENT TYPE (cont.)

Boards of Health:
Contractors that expend $500,000 or more in Federal awards during their fiscal year agree to have a single
entity-wide audit conducted for that year in accordance with the provisions of the Single Audit Act
Amendments of 1996 (Public Law 104-156) and their implementing regulation, OMB Circular A-133 entitled,

“Audits of States, Local Governments, and Nonprofit Organizations.” The audit reporting package shall
include the documents listed in Policy 1244 of the DHS Directives Information System.

Contractors expending $100,000 or more in State funds during their fiscal year agree to have an entity-
wide audit conducted for that year in accordance with Generally Accepted Auditing Standards issued by the
American Institute of Certified Public Accountants. The audit reporting package shall include the documents
listed in Policy 1244 of the DHS Directives Information System.

Contractor further agrees to submit two (2) copies of the required audit or financial statements within 180
days after the close of the Contractor’s fiscal year to:
        DHS Office of Inspector General
        Internal Audit Unit
        Room #26-425
        Two Peachtree Street, N.W.
        Atlanta, Georgia 30303-3142


Mental Health:
Contractors that expend $500,000 or more in Federal funds during their fiscal year agree to have a single
entity-wide audit conducted for that year in accordance with the provisions of the Single Audit Act
Amendments of 1996 (Public Law 104-156) and their implementing regulation, OMB Circular A-133 entitled,
“Audits of States, Local Governments, and Nonprofit Organizations.” The audit reporting package shall
include the documents listed in the Department of Human Services On-line Directives Information System
POL 1244, External Entities Audit Standards and Sanctions.

Contractors expending $100,000 or more in State funds during their fiscal year agree to have an entity-
wide audit conducted for that year in accordance with Generally Accepted Auditing Standards issued by the
American Institute of Certified Public Accountants. The audit reporting package shall include the documents
listed in the Department of Human Services On-line Directives Information System POL 1244, External
Entities Audit Standards and Sanctions.

Contractors expending at least $25,000 but less than $100,000 in State funds during their fiscal year agree
to prepare unaudited entity-wide financial statements for that year. Assertions concerning the basis of
financial statement preparation must be made by the president or other corporate official as described in the
Department of Human Services On-line Directives Information System POL 1244, External Entities Audit
Standards and Sanctions.

Contractor further agrees to submit two (2) copies of the required audit or financial statements within 180
days after the close of the Contractor’s fiscal year to the:

         DHS Office of Inspector General
         Internal Audits Unit
         Room #26-425
         Two Peachtree Street, N.W.
         Atlanta, GA 30303-3142

DFCS:
Audit requirements are handled by the state Division of Family & Children Services (DFCS) office. The
county DFCS office does not submit an audit for the Family Connection state grant.
                                                                            Resource Development and
                                                                            Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                        Page 16 of 26




CRITICAL INCIDENT REPORT
The fiscal agent is responsible for reporting any “Critical Incident” to DHS per the instructions in
“Annex E” of the FY12 Contract.

Copy of “Annex E, Critical Incident Report” follow.




                                                                       Resource Development and
                                                                       Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                   Page 17 of 26


                                                                        ANNEX E




                             Department of Human Services

                      Notice Concerning Critical Incident Reporting


Georgia Department of Human Services (DHS) requires that its
contractors/service providers make every reasonable effort to
ensure the safety of the individuals served through its programs.


To report an incident or situation that you feel may lead to serious
injury or death to a DHS client or consumer, please contact the
DHS Office of Inspector General at:


                   Telephone: 404-463-0121 (local Atlanta area)

           Or toll free outside of the Atlanta Area: 1-866-537-0109

                                Fax: 404-463-5496

                  Email: inspectorgeneralhotline@dhr.state.ga.us

                   Address: 2 Peachtree Street, NW, Suite 8-220

                              Atlanta, Georgia 30303




                                                       Resource Development and
                                                       Contract Management Team
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                  Page 18 of 26




                           I. Samples of CIMS FORMS

                             Annex B, Parts 1 and 2
                             Annex C, Parts 1 and 2




                                    II. Other

                  Family Connection Budget Revision Request
                    DHS Budget Preparation Allowable Costs
            Health/Medicaid Collaborative Partner Activity Categories




                                                      Resource Development and
                                                      Contract Management Team
      Fiscal Year 2012 Reports
      User’s Guide (9/11)                                                            Page 19 of 26
                                                                                  Annex B Part 1

                    Contract Budget and Quarterly Expenditure Report FY12

County:                                                                 Contract #:
Fiscal Agent:                                                           Quarter #:
Complete expenditure report in CIMS. Print, Sign and Date Report. Attach other required quarterly
reports. Reimbursement for quarterly expenditures will be delayed until all required reports are
ENTERED INTO CIMS AND SIGNED PRINTED COPIES ARE RECEIVED. Mail to:
 Contract Manager, Georgia Family Connection Partnership, 235 Peachtree St., Suite 1600, Atlanta, GA
                  30303-1422. Questions? Call Contract Manager at 404.527.7394

 EXPENSE TYPE                Family      Expenditures Prior               Total          Budget
                           Connection         for      Cumulative      Year to Date     Remainder
                            Approved    reimbursement Expenditures     Expenditures
                             Budget      for Quarter #
A. Personal                                   ___
Services
B. Regular
Operating

C. Travel (staff)
D. Equipment

E. Facility Costs                NA          NA             NA               NA               NA
F. Per Diem, Fees
& Contracts
G. Telecom-
munications
H. Other:

TOTAL
We, the undersigned, certify that the expenditures reported have been made for program
accomplishments within the approved budgeted items.

 ________________________                         __________________________
 Fiscal Agent Signature                           Collaborative Chairperson Signature
 ________________________                         ___________________________
 Print Name                                       Print Name

Date:_____________________                        Date:_______________________
For Office Use Only:

Date Received at Georgia Family Connection Partnership______________Initials____________


      Note: REPORTS SUBMITTED USING THIS FORM WILL NOT BE ACCEPTED. ENTER
            DATA INTO CIMS THEN PRINT, SIGN AND MAIL AS INDICATED ABOVE.
       Fiscal Year 2012 Reports
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                                                                                                                        0




                                                                                                         Annex B Part 2
                                         Family Connection State Grant
                                         Quarterly Subcontractor Report

County:                                                                                    Contract #:
Fiscal Agent:                                                                              Quarter #:
     Fiscal agents are required to complete this form if the above referenced contract has dollars
      budgeted under Line Item “F” – Per Diem, Fees and Contracts.
    The name, service, and amount of each subcontractor/vendor under the Family Connection
      contract must be listed in the table below.
    This form must be completed on CIMS, PRINTED FROM CIMS, signed by fiscal agent and
      attached to each Quarterly Expenditure Report (Annex B Part 1).
    Reimbursement for quarterly expenditures will be delayed if this form is not completed in CIMS,
     PRINTED FROM CIMS, signed and attached to Quarterly Expenditure Report (Annex B Part 1).
     Mail to:
     Contract Manager, Georgia Family Connection Partnership, 235 Peachtree St., Suite 1600,
     Atlanta, GA 30303-1422. Questions? Call Contract Manager at 404.527.7394

Name of Contractor                    Service               Total                  Amount              Small/Minority
                                     Provided            Subcontract            Expended this         Business Yes/No
                                                         Amount For                Quarter
                                                          The Year




                                  Total Amount Expended this Quarter for all subcontractors/vendors
              (Note: This amount should equal the requested reimbursement amount in Line item F on Annex B-1)


________________________
Fiscal Agent Signature
________________________
Print Name
Date:_____________________

       For Office Use Only:
       Date Received at Georgia Family Connection Partnership_____Initials__________

         Note: REPORTS SUBMITTED USING THIS FORM WILL NOT BE ACCEPTED.
        ENTER DATA INTO CIMS THEN PRINT, SIGN AND MAIL AS INDICATED ABOVE.
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User’s Guide (9/11)                                                              Page 21 of 26
                                                                             Annex C Part 1


                           Family Connection Quarterly Narrative Report

                                 (DATA TO BE ENTERED IN CIMS)
County:                                                  Contract #:
Fiscal Agent:                                            Quarter #:
                                                         Date:


Explain progress on the collaborative’s work in the following areas:
1. Collaborative Development and Operations:



2. Goal Implementation

Goal 1:

Goal 2:

Goal 3:

Goal 4:

Goal 5:

3. Evaluation:




Provide following information, if applicable:
4. List any specific training and technical assistance in which members of the
collaborative participated during the quarter.




For Office Use Only:

Date Received at Georgia Family Connection Partnership________Initials____________
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                                 Page 22 of 26



                                                                                    Annex C Part 2
                                   Family Connection
                                      Status Report
                           FY 2012 Plan Of Action (if Required)


          County: WeCare                                         Contract #:
          Fiscal Agent: WeCare County Board of                   Quarter #:
          Education
                                                                 Date:



         This is to verify that the development of the FY 2012 Plan of Action for the above
         referenced county has been completed as required.




         _____________________________
         Signature, Community Support Team Leader



         ______________________________
         Date




         Attach this Status Report to the Quarterly Report.




       For Office Use Only:

       Date Received at Family Connection Partnership____________Initials____________
            Fiscal Year 2012 Reports
            User’s Guide (9/11)                                                                                                    Page 23 of 26

                                                  Family Connection Budget Revision Request FY12


 County:                                                                                                    Contract #:
 Fiscal Agent:                                                                                              Revision #:


 Complete Budget Revision Request. Print, Sign and Date Report.
 Attach letter describing revisions and reason for request.

 Mail to:
 Contract Manager, Georgia Family Connection Partnership, 235 Peachtree St., Suite 1600, Atlanta, GA 30303-1422.

 Questions? Call Contract Manager at 404.527.7394


            EXPENSE TYPE
                                             Family Connection
                                                Approved                         Revised Amount                                Change
                                                  Budget


 A. Personal Services                              $39,250                            $36,567                                  (2,683)


 B. Regular Operating
                                                     2,853                              5,536                                   2,683

                                                       500
                                                    5,536
 C. Travel (staff)                                                                        500                                     -0-

 D. Equipment
                                                       0                                 0


 E. Facility Costs                                    NA                                NA                                       NA


 F. Per Diem, Fees & Contracts                         0                                 0

 G. Telecom-
                                                     1,397                              1,397
 munications

 H. Other:
                                                       0                                 0


 TOTAL                                             $44,000                            $44,000                                     $0

We, the undersigned, certify that the revisions listed above are correct and appropriate for the continuing operations of the Collaborative.



 ________________________                                                  __________________________
 Fiscal Agent Signature                                                    Collaborative Chairperson Signature

 ________________________                                                  ___________________________
 Print Name                                                                Print Name
 Date:____________________                                                 Date:_______________________

 For Office Use Only:
 Date printed from CIMS: April 17, 2012
 Date Received at Georgia Family Connection Partnership ______________Initials__________
         (Above is an example of a Family Connection Budget Revision Request. All Budget revisions are entered in CIMS and printed from
         CIMS. Refer to “Budget Revisions (including sample of CIMS letter)” earlier in this document for guidance on details for transmittal
         letter.)
Fiscal Year 2012 Reports
User’s Guide (9/11)                             Page 24 of 26


           DHS BUDGET PREPARATION ALLOWABLE COSTS
Fiscal Year 2012 Reports
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                                                                     DHS Budget Preparation Allowable Costs
Categorization of Expenses

Type of Expense                                   Includes but not limited to:                                                 Category                                  Non-Reimbursable
Contracts                                         Grant writing                                                                Per Diem Fees and Contracts               XXX
Advertising/ Fiscal Agent Management Fees         Costs to advertise, market programs, manage Family Connection grant          Regular Operating                         XXX
Audit                                             Fees associated with performance of an audit                                 Regular Operating
Client Benefits/Transportation                    Baby sitting services, etc.                                                  Other
Participant Transportation                        Costs to transport participants                                              Other
Computer Software                                 Expense for prepackaged software systems                                     Regular Operating
Consumer Support                                  Consumer meetings/planning                                                   Regular Operating
Contracts                                         Agreements for delivery of services evidenced by a written agreement         Per Diem, Fees and Contracts
Equipment (Office)                                Purchase of Computer                                                         Equipment
Equipment Maintenance/Repairs                     Contracts for maintenance of equipment and costs of repairs                  Regular Operating
Fringe Benefits                                   Benefits associated with employees, health insurance, FICA, etc.             Personal Services
Furniture and copier                              Purchase of office furniture and copier                                      Equipment                                 XXX
Insurance/Bonding                                 Fidelity bonds on employees and hazard coverage on property                  Regular Operating
Meetings                                          Room rental, refreshments, audio visual equipment                            Regular Operating
Per Diem and Fees                                 Architects, attorneys, consultants, temporary services                       Per Diem, Fees and Contracts
Postage                                           Costs incurred in mailing materials                                          Regular Operating
Printing                                          Letterhead stationery, imprinted envelopes, printed manuals, etc.            Regular Operating
Rent                                              Rental estate rental                                                         Facility Costs                            XXX
Salaries                                          Employee wages (hourly or salaried)                                          Personal Services
Subscriptions                                     Subscription to job-related publications/memberships in organizations        Regular Operating
Supplies (Operational)                            All types of consumable materials used in operations                         Regular Operating
Supplies (Program)                                Curricula, workbooks, video                                                  Regular Operating
Telecommunications/Telephone                      Telephone, telegraph, internet charges, beepers                              Telecommunications
Training/Conferences                              Registration fees or tuition                                                 Regular Operating
Travel                                            Lodgings, meals, use of vehicle for job-related activities                   Travel
Utilities                                         Electricity, natural gas, fuel oil, water and sewer charges                  Facility Costs                            XXX
Expenses unique to a funding source/program       Specified by funding source or program                                       Other

NOTE: Personal Services and Travel costs are budgeted only for Family Connection staff on the Fiscal Agent/ contractor’s payroll (if not on Fiscal Agent/ contractor’s payroll should be budgeted under
“Per Diem, Fees & Contracts”).
9/09
Fiscal Year 2012 Reports
User’s Guide (9/11)                                                            Page 26 of 26




 Health/Medicaid Collaborative and Collaborative Partner Activity Categories




Above categories are reported for both the collaborative’s and the collaborative partners’ activities
during the past quarter that link children to Health and Medicaid programs in the county. Data
informs the state Family Connection partner, Dept. of Community Health (DCH), on the outreach
activities occurring in the state during the previous quarter.

								
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