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New York State Employees Salaries

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					                                    New York State Education Department
                                        Request for Proposal #10-012
                                  NYS Statewide School Health Services Center
                                                 Budget Form




Instructions: Complete worksheets 1, 2 and 3 in their entirety.
Be certain to provide authorized signatures where required.

Worksheet #1 - provide the detailed expenditures for the first year of the project.

Worksheet #2 - provide a summary of expenditures for the entire project period (years 1 though 3.)

Worksheet #3 - provide a detailed description of subcontractor expenditures in year 1 and a subcontractor
expenditure summary for years 2 and 3.
                                       NYS Education Department
                              TECHNICAL ASSISTANCE CENTER (TAC) BUDGET
                                                   RFP #10-012
                                    NYS Statewide School Health Services Center
Agency Name:                                                            Contract Number:
                                                                            Budget Year: 1/1/11-12/31/11


Description                                                  FTE              Salary             Total
1. SALARIES: Include all staff attributable to this
agreement. One full-time equivalent (FTE) equals one
person working an entire week, each week of the
project. Express partial FTE's in decimals, e.g., a
teacher working one day per week equals .2 FTE.




1. Total Salaries


                                                                             # of Days           Total
2. PURCHASED SERVICES – Non-Employees.
Include consultants (indicate per diem rate), rentals,
tuition, and other contractual services.
Consultants (including travel, etc.)




2. Total Purchased Services




                                                                                              Page 2 of 8
                                     NYS Education Department
                            TECHNICAL ASSISTANCE CENTER (TAC) BUDGET
                                                  RFP #10-012
                                   NYS Statewide School Health Services Center
Agency Name:                                                           Contract Number:
                                                                           Budget Year: 1/1/11-12/31/11

3. EVENT COSTS: Detail all costs for allowable
expenses for any event to be provided as defined
within this agreement.                                # of Days         $ Rate/Day       Total




3. Total Event Costs


 4. SUPPLIES & MATERIALS, PRINTING - All
 equipment items having a unit value of less than
 $5,000 should be reported here.                                                                 Total




4. Total Supplies & Materials, Printing Costs

 5. TRAVEL EXPENSES (Employee Travel)                                                            Total




5. Total Travel Expenses




                                                                                             Page 3 of 8
                                     NYS Education Department
                            TECHNICAL ASSISTANCE CENTER (TAC) BUDGET
                                                  RFP #10-012
                                   NYS Statewide School Health Services Center
Agency Name:                                                           Contract Number:
                                                                           Budget Year: 1/1/11-12/31/11

 6. EMPLOYEE BENEFITS & OTHER COSTS                                                              Total




6. Total Employee Benefits & Other Costs


  7. INDIRECT COST:                                                                              Total
Direct Cost Base: Sum of all preceeding subtotals (1-
6), excluding the portion of each subcontract in #2
that exceeds $25,000.
Approved Indirect Cost Rate ______%
7. Total Indirect Cost


8. PURCHASED SERVICES WITH BOCES:
Description of Services                                 Name of BOCES Cost Calculation Total




8. Total Purchased Services with BOCES


9. EQUIPMENT                                            Quantity        Unit Cost        Total




9. Total Equipment

GRAND TOTAL



                                                                                             Page 4 of 8
         NYS Education Department
TECHNICAL ASSISTANCE CENTER (TAC) BUDGET
                    RFP #10-012
     NYS Statewide School Health Services Center




                                                   Page 5 of 8
                                       NYS Education Department
                              TECHNICAL ASSISTANCE CENTER (TAC) BUDGET
                                                     RFP #10-012
                                      NYS Statewide School Health Services Center
Agency Name:                                                                Contract Number:
                                                                                Budget Year: 1/1/11-12/31/11

                                                       BUDGET SUMMARY


SUBTOTAL                                                                                          PROJECT COSTS
1. SALARIES
2. PURCHASED SERVICES
3. EVENT COSTS
4. SUPPLIES & MATERIALS, PRINTING COSTS
5. TRAVEL EXPENSES
6. EMPLOYEE BENEFITS & OTHER COSTS
7. INDIRECT COST
8. PURCHASED SERVICES WITH BOCES
9. EQUIPMENT
GRAND TOTAL (January 1, 2011-December 31,
2011)

The NYS Statewide School Health Services Center budget is limited to 30% percent of the annual contract budget for
subcontracting purposes.

The Financial Criteria portion of the RFP will be scored based upon the grand total of the five-year Budget.




                                                                                                       Page 6 of 8
                                                      NYS Education Department
                                           TECHNICAL ASSISTANCE CENTER (TAC) BUDGET
                                       RFP #10-012 - NYS Statewide School Health Services Center
                                                           Budget Summaries for Years 1-5
                                                         January 1, 2011 - December 31, 2015

Agency Name:


Category                                         Year 1            Year 2            Year 3             Year 4      Year 5     Grand Total
                                                Projected         Projected         Projected          Projected   Projected    Projected
                                                 Amount            Amount            Amount             Amount      Amount       Amount
1. Salaries

2. Purchased Services

3. Event Costs

4. Supplies and Materials, Printing Costs

5. Travel

6. Employee Benefits and Other Costs

7. Indirect Costs

8. Purchased Services with BOCES

9. Equipment

Total


The financial Criteria portion of the RFP will be scored based upon the Grand Total five-year budget amount.

Vendor Signature

Printed Name

Company Name

Company Address

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                                                     NYS Education Department
                                RFP #10-012 NYS STATEWIDE SCHOOL HEALTH SERVICES CENTER
                                                     SUBCONTRACTING FORM
                                                 January 1, 2011 - December 31, 2015


Agency Name:                                                                                        Contract Number:

Subcontracting For First Twelve Months (January 1, 2011 - December 31, 2011)
Name of Subcontractor          Work Description & Estimated Hours/Days                                                    Projected
                                                                                                                          Cost




Total Subcontracting Cost        Total Project Budget               Percent of Subcontracting to Total Budget




                                Total Year 1   Total Year 2 Total Year 3   Total Year 4   Total Year 5    Grand Total
                                                                                                         Subcontracting
                                                                                                          For 5 Years

 Percent of Subcontracting to
       Annual Budget

The NYS Statewide School Health Services Center is limited to 30 percent of the annual contract budget for
subcontracting purposes.


Vendor Signature                                                                                         Date:

Printed Name

Company Name

Company Address



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