GEORGIA DEPARTMENT OF HUMAN RESOURCES GEORGIA DEPARTMENT OF JUVENILE JUSTICE ANNUAL COST REPORT

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GEORGIA DEPARTMENT OF HUMAN RESOURCES GEORGIA DEPARTMENT OF JUVENILE JUSTICE ANNUAL COST REPORT Powered By Docstoc
					                          GEORGIA DEPARTMENT OF HUMAN RESOURCES
                           GEORGIA DEPARTMENT OF JUVENILE JUSTICE
                                            ANNUAL COST REPORT
                                            FOR FISCAL YEAR 2007

Reporting Period                   From                                    To


Operating/Parent Agency
Mailing Address
City, State, Zip
Phone #                                                                     FAX #


Program Name*
Program Vendor Number
Program Site Address
City, State, Zip
Phone #                                                                     FAX #
* attach additional sheets if reporting costs for multiple program locations of the same program type - include detail

Primary Program Type (check one)CCI - LOC                                   CPA - LOC
If Other, specify                up to Level 3                               up to level 3
                                 up to level 4                               up to level 4
                                 up to level 5                               up to level 5
                                  Level 6                                   Level 6
                                Emergency Shelter
                                Maternity/Second Chance
                                Independent Living
                                Specialized Residential (DJJ)
                                Other
Hardware Secure (check one)        Yes              No
Program Category (check one)       Private Non-Profit             Private For-Profit              Public

CERTIFICATION OF ACCURACY:

Person Completing Form (Print):                                        Phone #:
   Signature:                                                           E-mail:
   Date:                                                                Fax#:

Authorized Agency Rep.(Print)                                          Phone #:
   Signature:                                                           E-mail:
   Date:                                                                Fax#:

Certifying Auditor (Print):                                            Phone #:
  Signature:                                                            E-mail:
  Date:                                                                 Fax#:
Page 1                                                                                                                                                         FY 2006

Program Name

CAPACITY AND UTILIZATION

Capacity
Licensed Capacity of Parent Agency
Licensed Capacity of this Program
Maximum Capacity of this Program (if less than licensed capacity)
Average Monthly Operational Capacity (Foster Care only)
Number of Months Operational during Report Period
Instructions
Licensed capacity of parent agency - the total licensed capacity of the provider agency of which this program is a part
Licensed capacity of this program - the number of licensed beds in the particular program/site covered by this cost report
Maximum capacity if less than licensed capacity - will be different than licensed capacity only if some beds were not operational during the report period
Average monthly operational capacity for Foster Care only - the average number of children served monthly by this program

Program Utilization by payment type                                 Number of Days Provided during the cost report period                    Count of Children Served
LOC                                                                      DFCS                   DJJ                  Other                    DFCS             DJJ
No level                                                                                                     XXXXXXXXXXXXXX
Level 1                                                                                                      XXXXXXXXXXXXXX
Level 2                                                                                                      XXXXXXXXXXXXXX
Level 3                                                                                                      XXXXXXXXXXXXXX
Level 4                                                                                                      XXXXXXXXXXXXXX
Level 5                                                                                                      XXXXXXXXXXXXXX
Level 6                                                                                                      XXXXXXXXXXXXXX
MAAC (Multi-Agency Alliance for Children)                                                                          XXXXXXXXXXXXXXX
DJJ Specialized Residential                                         XXXXXXXXXXXXXX                                 XXXXXXXXXXXXXXX
Other Public (Mental Health, other states)                          XXXXXXXXXXXXXX         XXXXXXXXXXXXXX
Private                                                             XXXXXXXXXXXXXX         XXXXXXXXXXXXXX
Total
Instructions - One bed filled = 1 day of care provided
 Page 2                                                                                                                         FY2006

Program Name _________________________________
                                                     PERSONNEL COST DETAIL
        I. Personnel/Costs
                                               Column 1         Column 2        Column 3   Column 4     Column 5    Column 6    Column 7
                                  Staff       Annual Salary    Administration     Time      Room &     Counseling    Medical    Unallowed
           Position Title      (FTE count)   (Paid/Accrued )                     Study       Board     or Therapy   Treatment

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

                                                                                                      XXXXXXXXXXX

A. Total Salaries
                                                                                                      XXXXXXXXXXX

B. Total Fringe
 Page 3                                                                                                                            FY2006

Program Name __________________________________
                                                        PERSONNEL COST DETAIL
        II. Contractor, Consultant &       Column 1          Column 2       Column 3       Column 4       Column 5     Column 6    Column 7
             Personal Services Cost        Annual or          Admin           Time         Room &         Counseling    Medical    Unallowed
                   (Specify)               Total Cost          Cost          Study          Board         or Therapy   Treatment

Payments to Foster Parents




A. Total Contractor Costs

B. Indirect Agency Costs *                                 * Indirect Agency Costs must be specified on Attachment A
Page 4                                                                                                                  FY2006


    Program Name ________________________________
                                                    PROGRAM COST DETAIL
           III. Consumable Supplies and          Column 1    Column 2    Column 4    Column 5      Column 6     Column 7
                Miscellaneous Expenses            Annual      Admin       Room &     Counseling     Medical     Unallowed
                                                   Cost        Cost        Board     or Therapy    Treatment

    A. Office Supplies

    B. Postage

    C. Printing

    D. Telephone

    E. Program, Vocational, and Craft Supplies

    F. Health and First Aid Supplies

    G. Food & Beverage

    H. Household & Janitorial Supplies

    I. Children's Allowances/Gifts
                                                            XXXXXXXXXX              XXXXXXXXXX    XXXXXXXXXX   XXXXXXXXXX
    J. Children's Clothing/Incidentals
                                                            XXXXXXXXXX              XXXXXXXXXX    XXXXXXXXXX   XXXXXXXXXX
    K. Children's School Supplies
                                                            XXXXXXXXXX              XXXXXXXXXX    XXXXXXXXXX   XXXXXXXXXX
    L. Children's After-school care
                                                            XXXXXXXXXX              XXXXXXXXXX    XXXXXXXXXX   XXXXXXXXXX
    M. Professional Dues, Subscriptions, etc.

    N. Other (specify)




    III. Total Consumable
Page 7                                                                                                                             FY 2006



Program Name __________________________________________


                                          COST REPORT AND AUDIT RECONCILIATION

Program Cost Totals                     Cost Report                            Revenue Totals                        Cost Report
Personnel - Salaries (pg 2)                                                    USDA
Personnel - Fringe (pg 2)                                                      Other Federal
Personnel - Contract (pg 3)                                                    Education
Personnel - Indirect (pg 3)                                                    DFCS
Consumables (pg 4)                                                             DJJ
Occupancy (pg 5)                                                               Mental Health
Travel (pg 5)                                                                  Other Public
Equipment (pg 5)                                                               Private
Education (pg 5)
Total Program Cost per Cost Report                                             Total Program Revenue per Cost Rpt.

Program Cost per Audit                                                         Program Revenues per Audit

Variance                                                                       Variance


Please explain any variances (other than those due to rounding). Attach additional pages/worksheets if necessary.
Page 5                                                                                                                                                       FY2006




Program Name __________________________
                                                        PROGRAM COST DETAIL
                COST ITEM                 ANNUAL COST                                        COST ITEM                          ANNUAL COST

        1. Occupancy Cost Detail     Allowable       Unallowable                      3. Equipment Cost Detail             Allowable       Unallowable

A. Mortgage Interest                                 XXXXXXXXXX                A. Vehicle/Equip. Loan Interest                             XXXXXXXXXX
                                                     XXXXXXXXXX                                                                            XXXXXXXXXX
B.   Mortgage Principal             XXXXXXXXXX                                 B. Vehicle/Equip Principal                 XXXXXXXXXX
C.   Depreciation of Building                                                  C. Rental & Maintenance of
D.   Rent/Lease                                                                   Equipment (Not Vehicle)
E.   Building Insurance                                                        D. Vehicle Lease
F.   Utilities                                                                 E. Depreciated Equipment
G.   Property Tax
H.   Maintenance & Repair
I.   Other (Must Specify):



                                                                       Total                                                                                 Total
            Total Occupancy Cost                 +                 =                      Total Equipment Cost                         +                 =


           2. Travel Cost Detail     Allowable       Unallowable                       4. Education Cost Detail            Allowable       Unallowable

A. Purchased Transportation                                                    A.   Salaries (on-site school)
   for client                                                                  B.   Classroom Cost (on-site school)
B. Agency Vehicle Operating Cost                                               C.   Classroom Supplies (on-site school)
C. Agency Vehicle Insurance                                                    D.   Tuition (off-site school)
D. Staff Mileage Reimbursement                                                 E.   Other (Must Specify)
E. Transportation Rental
F. Other (Must Specify)



                                                                       Total                                                                                 Total
               Total Travel Cost                 +                 =                      Total Education Cost                         +                 =
Page 6                                                                                                               FY2006




  Program Name _________________________________________
                                                                  REVENUE SOURCES
               List all Sources of Revenue for this Program Including:              List the amount of the Revenue

  Direct paid USDA/school lunch/food subsidy

  Other Federal (e.g., SSI payments) - must specify

  Education Funds - must specify

  DFCS Level of Care

  DFCS funds other

  DJJ Level of Care

  Department of Juvenile Justice

  Division of Mental Health

  MAAC (Multi- Agency Alliance for Children)

  Other public (local governments, other states)

  Private (donations, interest income, endowments, private pay) - must specify




                              TOTAL REVENUE AMOUNT
Page 8                                                                    FY2006
         Program Name ________________________________
                                           Attachment A

                                Detail of Indirect Agency Costs
                         Allowable Costs                          Total
                            Description                           Cost




         TOTAL INDIRECT AGENCY COST

				
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