Excess Proceeds Claim Form by ped96069

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									fd5fd1c4-24c1-4130-94f2-156377f8dd75.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

								
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