Get documents about "Excess Proceeds Claim Form - Excel
Description
Excess Proceeds Claim Form document sample
Document Sample
fb69785b-301d-47cb-be21-75ea525bad63.xls Intro
Index:
Cover Sheet
Narrative
LE Monthly
Milestone Chart
Statistical Summary
Claim Form 200
MVE Form 201
Personnel Services Form 201A
Equip Form 202
GOHS Cost Category Form 204
Payables Form 300
Property Management Form 301 pg1
Property Management Form 301 pg2
Budget Revision Form 100R
Budget Revision Form 101R
Budget Revision Form 102R
GOVERNOR'S OFFICE OF HIGHWAY SAFETY
MONTHLY PROGRAMMATIC REPORT
COVER PAGE
Month:
Agency: Project No.
Total Unit Work Hours: Prepared by:
Total Amount of Project: Project Title:
Agency Personnel: Authorized Employed
Project Personnel: Authorized Employed
DATE DATE
EMPLOYEE TITLE ASSIGNED REASSIGNED
(PAID UNDER PERSONNEL SERVICES)
Signature Project Director Signature, Author of Report
(If different from Project Director)
Date: Date
GOVENOR’S OFFICE OF HIGHWAY SAFETY
MONTHLY PROGRAMMATIC REPORT
NARRATIVE
Agency____________________________________
Project Number:____________________________
Reporting Month(s):_________________________
1. List Objectives: (List monthly objectives as detailed on your milestone chart and
describe how each was met.)
2. Accomplishments/Highlights: (Provide a detailed description of outstanding
achievements/highlights. Planned or Unexpected.)
3. Challenges: (Identify obstacles that prevented the project from reaching all
planned objectives.)
4. P.I.&E.: (Identify/Discuss all Public Information and Education Activities
conducted during the month. Attach newspaper articles, pictures, agendas,
material distributed, video documentation, etc…to support activities.)
5. Future Events Planned.
LAW ENFORCEMENT ONLY
GOVERNOR'S OFFICE OF HIGHWAY SAFETY
MONTHLY PROGRAMMATIC REPORT
MONTH: _____________________
AGENCY:_________________________________ PROJECT NUMBER:_____________________________
Enforcement Data NETWORK Participation
Grant Project Citations Only
# of Citations Participated in network activities
Arrest
Child Restraint Number of meetings attended
D.U.I.
Drug Arrest Number of multi-agency efforts
Following Too Close
Improper Lane Change
Other Felony Arrest
Reckless Driving LOCAL CRASH DATA
Red Light Violations
Seat Belt CRASHES INJURIES FATALITIES TOTAL
Speeding SPEED
Stolen Vehicle Recovered IMPAIRED DRIVING
Susp/Revoked License UNRESTRAINED
Uninsured Motorist PEDESTRIAN
Aggressive Driving OTHER
Eluding a Police Officer TOTAL
Other Citations
Total 0
GOVERNOR'S OFFICE OF HIGHWAY SAFETY
MILESTONE CHART
Governmental Unit: Department/Division
Project Title: Project No.:
Yearly
Oct. Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Totals
Objective/Activity: 0
Actual: 0
Objective/Activity: 0
Actual: 0
Objective/Activity: 0
Actual: 0
Objective/Activity: 0
Actual: 0
Objective/Activity: 0
Actual: 0
Objective/Activity: 0
Actual: 0
Objective/Activity: 0
Actual: 0
Objective/Activity: 0%
Actual: 0%
Objective/Activity: 0%
Actual: 0%
GOVERNOR'S OFFICE OF HIGHWAY SAFETY
STATISTICAL SUMMARY
Governmental Unit: Department/Division
Project Title: Project No.:
Yearly
Oct. Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Totals
Number of people reached 0
Number of adults reached (20 years and Up) 0
Number of youths reached (15 years-19 years) 0
Number of childern reached (0-14 years) 0
Total P.I.& E. distributed 0
Child Safety Seats distributed 0
Trainings conducted 0%
Exhibits participated in 0%
(SUMMARY)
PROJECT CLAIM FOR REIMBURSABLE EXPENDITURES (Form 200)
Month:
Government Unit: Claim Number
Project Title: GOHS Planner Approval:
Project Number: GOHS Finance Approval:
(1) (2) (3) (4) (5) (6)
Revision
Number _________
List Governmental Units or Prior Claims Amount of Year-to Date
Cost Categories Budget Total Total Amount This Claim Claims Balance
$ - $ - $ - $ - $ -
$ - $ - $ - $ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
TOTAL $ - $ - $ - $ - $ -
Local Cash Match @ ______%
Federal Participation @ ______% $ - $ - $ - $ - $ -
I certify that actual costs claimed have been incurred under the terms of the approved program and have not previously been
presented for payment.
Authorizing Official/ Date Project Director/Date
GOHS FORM 200
Revised 06/03
DETAIL FOR COST CATEGORY:
COST CATEGORY DETAIL: PERSONNEL SERVICES, MOTOR VEHICLE EXPENSES
(Form 201)
Month:
This form is to be completed for each project staff member
Claim Number: Pay Code: (h,w,b,s,m)
Employee Name: Effective Date Pay Raise:
Position Title: Vehicle Number:
Pay Rate: Make/Model/Year :
Daily Log of Hours Personnel Services
Worked and Miles Driven
(1) (2) (3) (4) (5)
Day of Total Actual Work Miles
the Scheduled Project Absence Driven
Month Work Hours Hours Code
Worked Total Salary Received this Month:
1
2 Salary Adjustments:
3 Regular (+/-)
4 Overtime (+/-)
5 Court (-)
6 Other (-)
7 Total Adjustments (+/-): $0.00
8
9 Project Salary to be claimed: $0.00
[Total salary to be claimed] Transfer to GOHS Form 201A)
10
11
12 Motor Vehicle Expenses
13
14 Odometer Reading
15
16 Start of Project:
17
18 Beginning of Month:
19
20 End of Month:
21
22 Charges Quanity Cost
23
24 Gasoline $ -
25
26 Oil $ -
27
28 Tires (Attach Invoice) $ -
29
30 Brakes (Attach Invoice) $ -
31
TOTAL 0.00 0.00 0.00 Total Cost for MVE (To Form 200) $ -
Employee Signature: Cost Per Mile $ -
GOHS Form 201
Revised 12/02
COST CATEGORY DETAIL: PERSONNEL SERVICES - SUMMARY SALARY AND FRINGE BENEFITS
(Form 201A)
For Month of:
Governmental Unit Claim Number
Project Number:
(a) Summary of Salaries charged to Project ( From 201 Forms)
(b) Summary of Fringe Benefits
FICA $ -
Retirement $ -
Health Insurance $ -
Life Insurance $ -
Life Insurance $ -
(g) Total of Fringe Benefits $ 0.00
(h) TOTAL PERSONNEL SERVICES (To Form 200) $ 0.00
GOHS Form 201A
(Revised 02/01)
COST CATEGORY DETAIL: EQUIPMENT PURCHASES INDIVIDUALLY OF $5,000.00 OR MORE (Form 202)
(Attach Documentation with Claim)
Governmental Unit (1) Total Equipment Budget Amount
Original $ -
Project Number
Revision No $ -
Federal Participation (%)
GOHS USE ONLY
(2) (3) (4) (5) (6) (7) (8)
Claim Invoice Invoice Serial Number/ Item Location of
No. No. Date Description of Equipment ID Number Cost Equipment Equip No. Type Loc.
(9) TOTAL $ -
When there is no longer a need for any of the above items to accomplish the purpose of the project, whether or not project continues to be assisted by federal funds,
grantee agrees to use or dispose of such items in accordance with Property Management Standards in OMBA - 102 Attachment N. Grantee further agrees to immediately
notify Governor’s Office of Highway Safety in writing of all actions under the Standards.
Authorizing Official
Title
Date
GOHS Form 202
Revised 02/01
COST CATEGORY DETAIL (Form 204)
(Exclude Personnel Services Cost, and Equipment Purchases of $5,000 or More)
Cost Category: Month:
(Use a separate form for each category)
Governmental Unit: Claim Number:
Project Number:
(1) (2) Invoice (3) (4) (5)
Description of Purchase or
Vendor Number Date Item Expense Quantity Amount
(6) TOTAL Cost Category $0.00
*ATTACH ALL APPLICABLE INVOICES
GOHS Form 204
(Revised 02/01)
OUTSTANDING PAYABLES (Form 300)
(THIS IS NOT A CLAIM FORM)
Governmental Unit Submission date
Project Title Project Ending date
Project Number
(1) (2) (3) (4) (5) (6)
Cost Description Date Anticipated Estimated GOHS
Category of Item Ordered Receipt Date Cost Use
Copies of Purchase Order(s) Must be Attached
GOHS Form 300
(Revised 02/01)
GOVERNOR'S OFFICE OF HIGHWAY SAFETY
34 Peachtree Street
One Park Tower, Suite 1600
Atlanta, Georgia 30303
Tel (404) 656-6996 Fax (404) 651-9107
PROPERTY MANAGEMENT (Form 301)
GRANTEE: ___________________________ PROJECT NUMBER: ______________
The Governor's Office of Highway Safety retains an interest in any property obtained through
this project with a purchase price of $5,000 or more and maintains an inventory record of
these items. If the property is disposed of, GOHS must receive a copy of the documentation
that is indicated in items (a) through (f) on the next page.
If the fair market value was less than $5,000, GOHS no longer retains an interest and the item
will be deleted from the property inventory records. If the information indicates a fair market
value in excess of $5,000, GOHS will either:
(1) be due a portion of the proceeds from the sale, surplusing, or insurance collection
for any item not replaced; or
(2) retain an interest in the new property acquired as replacement in the case of
trade-in, insurance proceeds, or remounting. In both cases, the amount of our
interest in the proceeds or replacement equipment will be the percentage of federal
participation in the purchase of the property.
NOTE: If the disposition of the property resulted in proceeds in excess of $5,000 which were
not used to replace the equipment, the grantee should also include a check payable
to the Governor's Office of Highway Safety for the amount due based on its interest in
the property. Please verify with GOHS the federal participation rate at which the
property was purchased prior to submission of this form and any reimbursement.
GOHS Form 301
Page 1 of 2
PROPERTY MANAGEMENT (Continued)
(LIST EACH ITEM OF EQUIPMENT SEPARATELY)
Disposition # Amount Serial Number Description
PROPERTY DISPOSTION
(a) If the property was sold; Indicate the amount of the sale proceeds
received.
(b) If the property was traded in; Indicate trade in value received. If in
excess of $5,000.00, attach a copy of the invoice of the equipment
purchased so our interest can be transferred in GOHS property
(c) If the property was stolen or destroyed; Indicate if it was insured and
the insurance amount received. If not insured, please so indicate. If the
insurance proceeds were used to replace the equipment, a copy of the
invoice for the new equipment should also be attached so GOHS
interest can be transferred in our property records.
(d) If the property was surplused; Send information on the date to whom it
was surplused, and amount of funds received, if any.
(e) Other; ___________________________________
Signature Date
Phone Number
GOHS Form 301
Page 2 of 2
(Revision Form)
SUMMARY OF PROJECT BUDGET DETAIL
(Form 100R)
Governmental Unit: Date:
Project Title: Project Number:
Continuation _______ Improvement/Expansion/Enhancement: New Project:_______
REVISION NUMBER _______
Adjusted Amount (The Revised Budget
Cost Category Original Budget total on line 10 should be zero) TOTAL
1. Personnel Services (salary & fringes) $ -
2. Regular Operating $ -
3. Travel $ -
4. Per Diem & Fees $ -
5. Contractual Services $ -
6. Telecommunications $ -
7. Equipment Purchases $ -
8. Computer Charges $ -
9. Motor Vehicle Equipment Purchases $ -
10. TOTAL
(The original Budget TOTAL and the Revised Budget
TOTAL should be the same) $ - $ - $ -
MATCHING FUNDS
11. Local Cash Match @
(percentage of total in Item 10)
12. Federal Participation @ _________%
(percentage of total in Item 10)
GOHS Form 100R
(Revision Form)
PERSONNEL SERVICE DETAIL
(Form 101R)
Governmental Unit Revision Number
Project Title: Date:
Project Number:
(1) (2) (3) (4) (5) (6) (7)
Hours Per Pay Annual Percent of
Position/Title Pay Code Wk Rate Salary Time Project Salary
TOTAL PROJECT SALARIES
(The total amount listed in the Project Salary column) $ -
(8) FRINGE BENEFITS – DESCRIPTION
(Fringe benefits may include the following:) Percentage Amount
F.I.C.A.
Retirement
Health Insurance
Worker’s Comp.
Unemployment Insurance
Other
TOTAL FRINGE BENEFITS $ -
TOTAL PERSONAL SERVICE
(total salaries + fringe benefits) $ -
ROUND OFF TOTAL TO NEAREST HUNDRED DOLLARS
(Transfer to GOHS Form 100R) $ -
GOHS Form 101R
(Revision Form)
COST CATEGORY DETAIL
(Form 102R)
(1) Cost Category
Governmental Unit:
Project Title:
Project Number:
Date: Revision Number:
(2) (3) (4) (5)
Description Unit Price Quantity TOTAL COST
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
(f) TOTAL COST $ -
(g) Round off to nearest $100
(Transfer to GOHS Form 100R) $ -
GOHS Form 102R
Related docs
