Rider to the Agreement

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					                                            RIDER F-1
                                 AGREEMENT SETTLEMENT FORM (ASF)
                                   PRO-FORMA - FEE FOR SERVICE
                                                     (see MAAP )

Community Agency:
Fiscal Year End:
Funding Department:
Agreement # DHHS:
Agreement Period:
Agreement Amount:

24 MONTHLY PAYMENTS PER AGREEMENT:                                                MONTH      AMOUNT
                            State Fiscal Year 2012
                                                                              1                       0.00
                                                                              2                       0.00
                                                                              3                       0.00
                                                                              4                       0.00
                                                                              5                       0.00
                                                                              6                       0.00
                                                                              7                       0.00
                                                                              8                       0.00
                                                                              9                       0.00
                                                                             10                       0.00
                                                                             11                       0.00
                                                                             12                       0.00
                                  State Fiscal Year 2013
                                                                             13                       0.00
                                                                             14                       0.00
                                                                             15                       0.00
                                                                             16                       0.00
                                                                             17                       0.00
                                                                             18                       0.00
                                                                             19                       0.00
                                                                             20                       0.00
                                                                             21                       0.00
                                                                             22                       0.00
                                                                             23                       0.00
                                                                             24                       0.00

                                                           TOTAL PAYMENTS:                            0.00

The total amount of the payments will not exceed the Agreement amount.

                                                                                          Rider F-1 ASF
Rider F-1 ASF
                                       RIDER F-2 AGREEMENT COMPLIANCE FORM

This section identifies compliance requirements that must be considered in audits of agreements between the Department and
Community Agency. Below is a summary of required compliance tests as well as sections within the agreement award relevant t
such testing. Failure to comply with any of these areas could lead to material deficiencies.

            Review the Federal compliance requirements specific to the following CFDA identifiers:

                CFDA #                              CFDA #                                CFDA #

            and review all the State compliance requirements listed below that apply to Federal Funds.

            Review the State compliance requirements in applicable areas specified below:

                               1.) INTERNAL CONTROL

                               2.) STANDARD ADMINISTRATIVE PRACTICES
                                       A. OMB A-110/Common Rule                               B. Department Additions
                                          Pre-award Requirements
                                          Financial and Program Management                         Standards for Bonding
                                          Property Standards                                       Program Budget
                                          Procurement Standards
                                          Reports and Records
                                          Termination and Enforcement
                                          After the Award Requirements

                               3.) ACTIVITIES ALLOWED OR UNALLOWED                                       Rider A Section III

                               4.) ALLOWABLE COSTS/COST PRINCIPLES
                                          OMB A-122                OMB A-87

                               5.) CASH MANAGEMENT

                               6) ELIGIBILITY                                                                 Rider E

                               7.) EQUIPMENT AND REAL PROPERTY MANAGEMENT

                               8.) MATCHING, LEVEL OF EFFORT, EARMARKING

                               9.) PERIOD OF AVAILABLITY OF FUNDS

                               10.) PROCUREMENT AND SUSPENSION AND DEBARMENT                             Rider D Section 6

                               11.) PROGRAM INCOME

                               12.) REPORTING                                                            Rider A Section II

                               13.) SUBRECIPIENT MONITORING                                              Rider D Section 17

                               14.) SPECIAL TESTS AND PROVISIONS

                               15.) AGREEMENT SETTLEMENT METHOD: COST SHARED
                                   (Check all that are applicable) NON-COST SHARED
                                                                                                         Rider F-1 ASF

                    Rider F-1 ASF
n the Department and a
ement award relevant to

ment Additions

rds for Bonding
m Budget

Rider A Section III

         OMB A-21

     Rider E

Rider D Section 6

Rider A Section II

Rider D Section 17

                          Rider F-1 ASF
Rider F-1 ASF

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