Common use of CFDA Number(s Clause in Contracts

CFDA Number(s. When applicable, the Grantee shall inform its licensed independent public accountant of the federal regulations that are to be complied with in the performance of an audit. This information shall consist of the following Catalog of Federal Domestic Assistance Numbers: 93.387 Tennessee State-Based Tobacco Prevention and Control Program IN WITNESS WHEREOF, GRANTEE LEGAL ENTITY NAME: GRANTEE SIGNATURE DATE PRINTED NAME AND TITLE OF GRANTEE SIGNATORY (above) DEPARTMENT OF HEALTH: XXXX XXXXXXX, MD, MBA, FAAP, COMMISSIONER DATE Attachment 1 Grantee’s Application 00-00-00 XX XXXXXXXXXX 2 Federal Award Identification Worksheet Subrecipient’s name (must match registered name in DUNS) Subrecipient’s DUNS number Federal Award Identification Number (XXXX) Federal award date CFDA number and name Grant contract’s begin date Grant contract’s end date Amount of federal funds obligated by this grant contract Total amount of federal funds obligated to the subrecipient Total amount of the federal award to the pass-through entity (Grantor State Agency) Name of federal awarding agency Name and contact information for the federal awarding official Is the federal award for research and development? Indirect cost rate for the federal award (See 2 C.F.R. §200.331 for information on type of indirect cost rate) GRANT BUDGET (BUDGET PAGE 1) ADDITIONAL IDENTIFICATION INFORMATION AS NECESSARY APPLICABLE PERIOD: The grant budget line-item amounts below shall be applicable only to expense incurred during the period beginning DATE, and ending DATE. POLICY 03 Object Line-item Reference EXPENSE OBJECT LINE-ITEM CATEGORY 1 (detail schedule(s) attached as applicable) GRANT CONTRACT GRANTEE PARTICIPATION TOTAL PROJECT 1 Salaries2 $0.00 $0.00 $0.00 2 Benefits & Taxes $0.00 $0.00 $0.00 4, 15 Professional Fee/ Grant & Award 2 $0.00 $0.00 $0.00 5 Supplies $0.00 $0.00 $0.00 6 Telephone $0.00 $0.00 $0.00 7 Postage & Shipping $0.00 $0.00 $0.00 8 Occupancy $0.00 $0.00 $0.00 9 Equipment Rental & Maintenance $0.00 $0.00 $0.00 10 Printing & Publications $0.00 $0.00 $0.00 11, 12 Travel/ Conferences & Meetings2 $0.00 $0.00 $0.00 13 Interest 2 $0.00 $0.00 $0.00 14 Insurance $0.00 $0.00 $0.00 16 Specific Assistance To Individuals2 $0.00 $0.00 $0.00 17 Depreciation 2 $0.00 $0.00 $0.00 18 Other Non-Personnel 2 $0.00 $0.00 $0.00 20 Capital Purchase 2 $0.00 $0.00 $0.00 22 Indirect Cost (% and method) $0.00 $0.00 $0.00 24 In-Kind Expense $0.00 $0.00 $0.00 25 GRAND TOTAL $0.00 $0.00 $0.00 1 Each expense object line-item shall be defined by the Department of Finance and Administration Policy 03, Uniform Reporting Requirements and Cost Allocation Plans for Subrecipients of Federal and State Grant Monies, Appendix A. (posted on the Internet at: xxxx://xxx.xx.xxx/finance/topic/fa-policyinfo). 2 Applicable detail follows this page if line-item is funded. GRANT BUDGET LINE-ITEM DETAIL (BUDGET PAGE 2) SALARIES AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) x x + (Longetivity, if applicable) $0.00 ROUNDED TOTAL $0.00 PROFESSIONAL FEE/ GRANT & AWARD AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 TRAVEL/ CONFERENCES & MEETINGS AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 INTEREST AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 SPECIFIC ASSISTANCE TO INDIVIDUALS AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 DEPRECIATION AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 OTHER NON-PERSONNEL AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 CAPITAL PURCHASE AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 STATE OF TENNESSEE INVOICE FOR REIMBURSEMENT For ACCOUNTS MANAGEMENT OFFICE USE ONLY PO# LINE# RECEIPT # TDOH AGENCY INVOICE # EDISON CONTRACT # EDISON VENDOR # EDISON ADDRESS LINE # VOUCHER # NAME AND REMITTANCE ADDRESS OF CONTRACTOR/GRANTEE INVOICE NUMBER INVOICE DATE INVOICE PERIOD FROM TO Edison Vendor # CONTRACT PERIOD CONTRACTING STATE AGENCY Tennessee Department of Health FROM TO PROGRAM AREA CONTACT PERSON/TELEPHONE NO. OCR CONTRACT NUMBER (A) (B) (C) FOR CENTRAL OFFICE USE ONLY BUDGET TOTAL AMOUNT BILLED MONTHLY LINE CONTRACT YTD EXPENDITURES SPEEDCHART NUMBER: ITEMS BUDGET DUE USERCODE: PROJECT ID: (MO./DAY/YR.) AMOUNT: Salaries Benefits SPEEDCHART NUMBER: Professional Fee/Grant & Award USERCODE: Supplies PROJECT ID: Telephone AMOUNT: Postage & Shipping Occupancy SPEEDCHART NUMBER: Equipment Rental & Maintenance USERCODE: Printing & Publications PROJECT ID: Travel/Conferences & Meetings AMOUNT: Interest Insurance SPEEDCHART NUMBER: Specific Assistance to Individuals USERCODE: Depreciation PROJECT ID: Other Non Personnel AMOUNT: Capital Purchase Indirect Cost TOTAL I certify to the best of my knowledge and belief that the data Please check one of the following boxes above are correct, that all expenditures were made in These services are for medical services accordance with the contract conditions, and that payment is due and has not been previously requested. non-medical services RECOMMENDED FOR PAYMENT CONTRACTOR'S/GRANTEE'S AUTHORIZED SIGNATURE PROGRAM APPROVAL AUTHORIZED SIGNATURE CONTRACTING STATE AGENCY'S AUTHORIZED CERTIFICATION FOR FISCAL USE ONLY Title: Title: Title: Date: Date: Date: ATTACHMENT: Instructions & Hints Do not send a worksheet that is linked to another file Line by line instructions are on the "line by line info" tab Retain this file in blank form Use "File Save As" to save information for a specific contract or reporting period File Names: Please use the following format when naming files. name of agency REPORTING PERIOD END.xls do not abbreviate the agency name example: davidson county health MARCH 02.xls Reporting period - the start and end dates of the quarter being reported Reporting periods are based on the Agency's fiscal year Grant period - the start and end dates of the contract being reported Send a report for every quarter even if there is no activity for that quarter Abbreviations - do not abbreviate the Agency name Number pages using the "page of pages" format THE WORKSHEET IS NOT PROTECTED do not overwrite formulas (identified by yellow shading and "0" ) or change formats do not overwrite/edit shaded areas (move to the cell beyond the shading for input) do not add (insert) lines do not change shaded areas Expense and Revenue pages can show information for 2 contracts Use separate Schedules A & B to report contracts for each granting State agency Use additional expense and revenue pages for more than 2 contracts copy all lines & fields to the first blank line below the last line in column A with the cursor at the start of the added page, use "insert" "page break" for print purposes reset print range to cover the added page(s) and correct the page numbers Contract Number is the State Contract Number, NOT the agency program number Report by program within the State Contract Number within State Department Summarize programs into totals by State Contract Number and State Department totals Do not combine State Contract Numbers One Funding Information Summary and one Schedule C are required from each contractor submitting reports Review Section C in all contracts for reporting requirements ALLOCATION OF ADMINISTRATIVE COSTS Requires completion of all attached sheets NOTE If files are not properly named and print ranges not set, the report will be returned for correction Do not send invoices with expense reports If refund due, mail reports with check or send note with e-mail that check in the mail e-mail completed files to: Xxxxxx0.XXX.Xxxxxx@xx.xxx e-mail filing replaces mailing forms Mailing Address: Monaliz Hana Telephone 000-000-0000 Tennessee Department of Health Fiscal Services 6th Floor Xxxxxx Xxxxxxx Tower 000 Xxxxx Xxxxxxxxx Parkway Nashville, TN 37243 Attachment 5 PROGRAM EXPENSE REPORT (Excerpted from Policy 3 statement) SCHEDULE A EXPENSE BY OBJECT LINE-I TEMS There are seventeen specific object expense categories; two subtotals (Line 3, Total Personnel Expenses, and Line 19, Total Non-personnel Expenses); and Reimbursable Capital Purchases (Line 20), above Line 21, Total Direct Program Expenses. All expenses should be included in one or more of the specific categories, or in an additional expense category entered under Line 18, Other Non-personnel Expenses. The contracting state state agency may determine these requirements. With the exception of depreciation, everything reported in Lines 1 through 21 must represent an actual cash disbursement or accrual as defined in the Basis For Reporting Expenses/Expenditures section on page 13. THE YEAR-TO-DATE EXPENSES MUST BE TRACABLE TO THE REPORTI NG AGENCY'S GENERAL LEDGER Line 1 Salaries And Wages On this line, enter compensation, fees, salaries, and wages paid to officers, directors, trustees, and employees. An attached schedule may be required showing client wages or other included in the aggregations.

CFDA Number(s. When applicable, the Grantee shall inform its licensed independent public accountant of the federal regulations that are to be complied with in the performance of an audit. This information shall consist of the following Catalog of Federal Domestic Assistance Numbers: 93.387 Tennessee State-Based Tobacco Prevention and Control Program 93.060 – Sexual Risk Avoidance Education IN WITNESS WHEREOF, GRANTEE LEGAL ENTITY NAME: GRANTEE SIGNATURE DATE PRINTED NAME AND TITLE OF GRANTEE SIGNATORY (above) DEPARTMENT OF HEALTH: XXXX XXXXXXX, MD, MBA, FAAP, COMMISSIONER DATE Attachment ATTACHMENT 1 Grantee’s Application 00-00-00 XX XXXXXXXXXX GRANTEE’S PROPOSAL ATTACHMENT 2 Federal Award Identification Worksheet Subrecipient’s name (must match registered name in DUNSassociated with its Unique Entity Identifier (XXX) Subrecipient’s DUNS number Unique Entity Identifier (XXX) Federal Award Identification Number (XXXX) Federal award date Subaward Period of Performance Start and End Date Subaward Budget Period Start and End Date Assistance Listing number (formerly known as the CFDA number number) and name Assistance Listing program title. Grant contract’s begin date Grant contract’s end date Amount of federal funds obligated by this grant contract Total amount of federal funds obligated to the subrecipient Total amount of the federal award to the pass-through entity (Grantor State Agency) Federal award project description (as required to be responsive to the Federal Funding Accountability and Transparency Act (FFATA) Name of federal awarding agency Name and contact information for the federal awarding official Name of pass-through entity Name and contact information for the pass- through entity awarding official Is the federal award for research and development? Indirect cost rate for the federal award (See 2 C.F.R. §200.331 for information on type of indirect cost rate) ATTACHMENT 3 GRANT BUDGET (BUDGET PAGE 1) ADDITIONAL IDENTIFICATION INFORMATION AS NECESSARY APPLICABLE PERIOD: The grant budget line-item amounts below shall be applicable only to expense incurred during the period beginning DATE, and ending DATE. POLICY 03 Object Line-item Reference EXPENSE OBJECT LINE-ITEM CATEGORY 1 (detail schedule(s) attached as applicable) GRANT CONTRACT GRANTEE PARTICIPATION TOTAL PROJECT 1 Salaries2 $0.00 $0.00 $0.00 2 Benefits & Taxes $0.00 $0.00 $0.00 4, 15 Professional Fee/ Grant & Award 2 $0.00 $0.00 $0.00 5 Supplies $0.00 $0.00 $0.00 6 Telephone $0.00 $0.00 $0.00 7 Postage & Shipping $0.00 $0.00 $0.00 8 Occupancy $0.00 $0.00 $0.00 9 Equipment Rental & Maintenance $0.00 $0.00 $0.00 10 Printing & Publications $0.00 $0.00 $0.00 11, 12 Travel/ Conferences & Meetings2 $0.00 $0.00 $0.00 13 Interest 2 $0.00 $0.00 $0.00 14 Insurance $0.00 $0.00 $0.00 16 Specific Assistance To Individuals2 $0.00 $0.00 $0.00 17 Depreciation 2 $0.00 $0.00 $0.00 18 Other Non-Personnel 2 $0.00 $0.00 $0.00 20 Capital Purchase 2 $0.00 $0.00 $0.00 22 Indirect Cost (% and method) $0.00 $0.00 $0.00 24 In-Kind Expense $0.00 $0.00 $0.00 25 GRAND TOTAL $0.00 $0.00 $0.00 1 Each expense object line-item shall be defined by the Department of Finance and Administration Policy 03, Uniform Reporting Requirements and Cost Allocation Plans for Subrecipients of Federal and State Grant Monies, Appendix A. (posted on the Internet at: xxxx://xxx.xx.xxx/finance/topic/fa-policyinfoxxxxx://xxx.xx.xxx/content/dam/tn/finance/documents/fa_policies/policy3.pdf). 2 Applicable detail follows this page if line-item is funded. ATTACHMENT 3 (continued) GRANT BUDGET LINE-ITEM DETAIL (BUDGET PAGE 2) SALARIES AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) x x + (Longetivity, if applicable) $0.00 ROUNDED TOTAL $0.00 PROFESSIONAL FEE/ GRANT & AWARD AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 TRAVEL/ CONFERENCES & MEETINGS AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 INTEREST AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 SPECIFIC ASSISTANCE TO INDIVIDUALS AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 DEPRECIATION AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 OTHER NON-PERSONNEL AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 CAPITAL PURCHASE AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 STATE OF TENNESSEE INVOICE FOR REIMBURSEMENT For ACCOUNTS MANAGEMENT OFFICE USE ONLY PO# LINE# RECEIPT # TDOH AGENCY INVOICE # EDISON CONTRACT # EDISON VENDOR # EDISON ADDRESS LINE # VOUCHER # NAME AND REMITTANCE ADDRESS OF CONTRACTORXXXXXXXXXX/GRANTEE XXXXXXX XXXX AGENCY INVOICE NUMBER (ONLY FOR FISCAL OFFICE USE) INVOICE NUMBER INVOICE DATE INVOICE PERIOD FROM TO FEDERAL ID# Edison Vendor # CONTRACT PERIOD FROM TO CONTRACTING STATE AGENCY Tennessee Department of Health CONTRACT PERIOD PROGRAM AREA Small Hospital Improvement Program FROM TO PROGRAM AREA EDISON CONTRACT NUMBER CONTACT PERSON/TELEPHONE NO. OCR CONTRACT NUMBER (A) (B) (C) FOR CENTRAL OFFICE USE ONLY BUDGET TOTAL AMOUNT BILLED MONTHLY LINE CONTRACT YTD EXPENDITURES SPEEDCHART NUMBER: ITEMS BUDGET DUE USERCODE: PROJECT ID: (MO./DAY/YR.) AMOUNT: Salaries Benefits SPEEDCHART NUMBER: Professional Fee/Grant & Award USERCODE: Supplies PROJECT ID: Telephone AMOUNT: Postage & Shipping Occupancy SPEEDCHART NUMBER: Equipment Rental & Maintenance USERCODE: Printing & Publications PROJECT ID: Travel/Conferences & Meetings AMOUNT: Interest Insurance SPEEDCHART NUMBER: Specific Assistance to Individuals USERCODE: Depreciation PROJECT ID: Other Non Personnel AMOUNT: Capital Purchase Indirect Cost TOTAL I certify to the best of my knowledge and belief that the data Please check one of the following boxes above are correct, that all expenditures were made in These services are for medical services accordance with the contract conditions, and that payment is due and has not been previously requested. non-medical services RECOMMENDED FOR PAYMENT CONTRACTOR'S/GRANTEE'S AUTHORIZED SIGNATURE PROGRAM APPROVAL AUTHORIZED SIGNATURE CONTRACTING STATE AGENCY'S AUTHORIZED CERTIFICATION FOR FISCAL USE ONLY Name: Name: Name: Title: Title: Title: Date: Date: Date: ATTACHMENT: 4 Instructions & Hints Do not send a worksheet that is linked to another file Line by line instructions are on the "line by line info" tab Retain this file in blank form Use "File Save As" to save information for a specific contract or reporting period File Names: Please use the following format when naming files. name of agency REPORTING PERIOD END.xls do not abbreviate the agency name example: davidson county health MARCH 02.xls Reporting period - the start and end dates of the quarter being reported Reporting periods are based on the Agency's fiscal year Grant period - the start and end dates of the contract being reported Send a report for every quarter even if there is no activity for that quarter Abbreviations - do not abbreviate the Agency name Number pages using the "page of pages" format THE WORKSHEET IS NOT PROTECTED do not overwrite formulas (identified by yellow shading and "0" ) or change formats do not overwrite/edit shaded areas (move to the cell beyond the shading for input) do not add (insert) lines do not change shaded areas Expense and Revenue pages can show information for 2 contracts Use separate Schedules A & B to report contracts for each granting State agency Use additional expense and revenue pages for more than 2 contracts copy all lines & fields to the first blank line below the last line in column A with the cursor at the start of the added page, use "insert" "page break" for print purposes reset print range to cover the added page(s) and correct the page numbers Contract Number is the State Contract Number, NOT the agency program number Report by program within the State Contract Number within State Department Summarize programs into totals by State Contract Number and State Department totals Do not combine State Contract Numbers One Funding Information Summary and one Schedule C are required from each contractor submitting reports Review Section C in all contracts for reporting requirements ALLOCATION OF ADMINISTRATIVE COSTS Requires completion of all attached sheets NOTE If files are not properly named and print ranges not set, the report will be returned for correction Do not send invoices with expense reports If refund due, mail reports with check or send note with e-mail that check in the mail e-mail completed files to: Xxxxxx0.XXX.Xxxxxx@xx.xxx e-mail filing replaces mailing forms Mailing Address: Monaliz Hana Telephone 000-000-0000 Tennessee Department of Health Fiscal Services 6th Floor Xxxxxx Xxxxxxx Tower 000 Xxxxx Xxxxxxxxx Parkway Nashville, TN 37243 Attachment 5 PROGRAM EXPENSE REPORT (Excerpted from Policy 3 statement) SCHEDULE A EXPENSE BY OBJECT LINE-I TEMS There are seventeen specific object expense categories; two subtotals (Line 3, Total Personnel Expenses, and Line 19, Total Non-personnel Expenses); and Reimbursable Capital Purchases (Line 20), above Line 21, Total Direct Program Expenses. All expenses should be included in one or more of the specific categories, or in an additional expense category entered under Line 18, Other Non-personnel Expenses. The contracting state state agency may determine these requirements. With the exception of depreciation, everything reported in Lines 1 through 21 must represent an actual cash disbursement or accrual as defined in the Basis For Reporting Expenses/Expenditures section on page 13. THE YEAR-TO-DATE EXPENSES MUST BE TRACABLE TO THE REPORTI NG AGENCY'S GENERAL LEDGER Line 1 Salaries And Wages On this line, enter compensation, fees, salaries, and wages paid to officers, directors, trustees, and employees. An attached schedule may be required showing client wages or other included in the aggregations.

CFDA Number(s. When applicable, the Grantee shall inform its licensed independent public accountant of the federal regulations that are to be complied with in the performance of an audit. This information shall consist of the following Catalog of Federal Domestic Assistance Numbers: 93.387 Tennessee State-Based Tobacco Prevention and Control Program 93.478 Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees IN WITNESS WHEREOF, GRANTEE LEGAL ENTITY NAME: GRANTEE SIGNATURE DATE PRINTED NAME AND TITLE OF GRANTEE SIGNATORY (above) DEPARTMENT OF HEALTH: XXXX XXXXXXX, MD, MBA, FAAP, COMMISSIONER DATE Attachment 1 Grantee’s Application 00-00-00 XX XXXXXXXXXX 2 Federal Award Identification Worksheet Subrecipient’s name (must match registered name in DUNS) Subrecipient’s DUNS number Federal Award Identification Number (XXXX) NU58DP006681 Federal award date 7/12/2021 CFDA number and name 93.478 Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees Grant contract’s begin date January 1, 2022 Grant contract’s end date September 30, 2022 Amount of federal funds obligated by this grant contract $100,000.00 Total amount of federal funds obligated to the subrecipient Total amount of the federal award to the pass-pass- through entity (Grantor State Agency) $450,000.00 Name of federal awarding agency Centers for Disease Control and Prevention Name and contact information for the federal awarding official Xxxxxx Xxxxxxx Phone: 000-000-0000 XXX0@xxx.xxx Is the federal award for research and development? No Indirect cost rate for the federal award (See 2 C.F.R. §200.331 for information on type of indirect cost rate) 14.3% ATTACHMENT 3 (Continued) GRANT BUDGET (BUDGET PAGE 11 of 2) ADDITIONAL IDENTIFICATION INFORMATION AS NECESSARY VENDOR NAME APPLICABLE PERIOD: The grant budget line-item amounts below shall be applicable only to expense incurred during the period beginning DATE, and ending DATE. YEAR 1 POLICY 03 Object Line-item Reference EXPENSE OBJECT LINE-ITEM CATEGORY 1 (detail schedule(s) attached as applicable) GRANT CONTRACT GRANTEE PARTICIPATION TOTAL PROJECT 1 Salaries2 $0.00 $0.00 $0.00 2 Benefits & Taxes $0.00 $0.00 $0.00 4, 15 Professional Fee/ Grant & Award 2 $0.00 $0.00 $0.00 5 Supplies $0.00 $0.00 $0.00 6 Telephone $0.00 $0.00 $0.00 7 Postage & Shipping $0.00 $0.00 $0.00 8 Occupancy $0.00 $0.00 $0.00 9 Equipment Rental & Maintenance $0.00 $0.00 $0.00 10 Printing & Publications $0.00 $0.00 $0.00 11, 12 Travel/ Conferences & Meetings2 $0.00 $0.00 $0.00 13 Interest 2 $0.00 $0.00 $0.00 14 Insurance $0.00 $0.00 $0.00 16 Specific Assistance To Individuals2 $0.00 $0.00 $0.00 17 Depreciation 2 $0.00 $0.00 $0.00 18 Other Non-Personnel 2 $0.00 $0.00 $0.00 20 Capital Purchase 2 $0.00 $0.00 $0.00 22 Indirect Cost (% and method) $0.00 $0.00 $0.00 24 In-Kind Expense $0.00 $0.00 $0.00 25 GRAND TOTAL $0.00 $0.00 $0.00 1 Each expense object line-item shall be defined by the Department of Finance and Administration Policy 03, Uniform Reporting Requirements and Cost Allocation Plans for Subrecipients of Federal and State Grant Monies, Appendix A. (posted on the Internet at: xxxx://xxx.xx.xxx/finance/topic/fa-policyinfoxxxx://xxx.xx.xxx/finance/looking-for/policies.html). 2 Applicable detail follows this page if line-item is funded. YEAR 1 ATTACHMENT 3 (Continued) GRANT BUDGET LINE-ITEM DETAIL (BUDGET PAGE 2 of 2) SALARIES AMOUNT Name, Title Monthly Salary # of Months % of time SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) x x + (LongetivityLongevity, if applicable) $0.00 ROUNDED TOTAL $0.00 PROFESSIONAL FEE/ FEE / GRANT & AWARD AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 TRAVEL/ TRAVEL / CONFERENCES & MEETINGS AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 INTEREST AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 SPECIFIC ASSISTANCE TO INDIVIDUALS AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 DEPRECIATION AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 OTHER NON-PERSONNEL AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 CAPITAL PURCHASE AMOUNT SPECIFIC, DESCRIPTIVE, DETAIL (REPEAT ROW AS NECESSARY) $0.00 ROUNDED TOTAL $0.00 STATE OF TENNESSEE INVOICE FOR REIMBURSEMENT For ACCOUNTS MANAGEMENT OFFICE USE ONLY PO# LINE# RECEIPT # TDOH AGENCY INVOICE # EDISON CONTRACT # EDISON VENDOR # EDISON ADDRESS LINE # VOUCHER # NAME AND REMITTANCE ADDRESS OF CONTRACTOR/GRANTEE INVOICE NUMBER INVOICE DATE INVOICE PERIOD FROM TO Edison Vendor # CONTRACT PERIOD CONTRACTING STATE AGENCY Tennessee Department of Health FROM TO PROGRAM AREA CONTACT PERSON/TELEPHONE NO. OCR CONTRACT NUMBER (A) (B) (C) FOR CENTRAL OFFICE USE ONLY BUDGET TOTAL AMOUNT BILLED MONTHLY LINE CONTRACT YTD EXPENDITURES SPEEDCHART NUMBER: ITEMS BUDGET DUE USERCODE: PROJECT ID: (MO./DAY/YR.) AMOUNT: Salaries Benefits SPEEDCHART NUMBER: Professional Fee/Grant & Award USERCODE: Supplies PROJECT ID: Telephone AMOUNT: Postage & Shipping Occupancy SPEEDCHART NUMBER: Equipment Rental & Maintenance USERCODE: Printing & Publications PROJECT ID: Travel/Conferences & Meetings AMOUNT: Interest Insurance SPEEDCHART NUMBER: Specific Assistance to Individuals USERCODE: Depreciation PROJECT ID: Other Non Personnel AMOUNT: Capital Purchase Indirect Cost TOTAL I certify to the best of my knowledge and belief that the data Please check one of the following boxes above are correct, that all expenditures were made in These services are for medical services accordance with the contract conditions, and that payment is due and has not been previously requested. non-medical services RECOMMENDED FOR PAYMENT CONTRACTOR'S/GRANTEE'S AUTHORIZED SIGNATURE PROGRAM APPROVAL AUTHORIZED SIGNATURE CONTRACTING STATE AGENCY'S AUTHORIZED CERTIFICATION FOR FISCAL USE ONLY Title: Title: Title: Date: Date: Date: ATTACHMENT: Instructions & Hints Do not send a worksheet that is linked to another file Line by line instructions are on the "line by line info" tab Retain this file in blank form Use "File Save As" to save information for a specific contract or reporting period File Names: Please use the following format when naming files. name of agency REPORTING PERIOD END.xls do not abbreviate the agency name example: davidson county health MARCH 02.xls Reporting period - the start and end dates of the quarter being reported Reporting periods are based on the Agency's fiscal year Grant period - the start and end dates of the contract being reported Send a report for every quarter even if there is no activity for that quarter Abbreviations - do not abbreviate the Agency name Number pages using the "page of pages" format THE WORKSHEET IS NOT PROTECTED do not overwrite formulas (identified by yellow shading and "0" ) or change formats do not overwrite/edit shaded areas (move to the cell beyond the shading for input) do not add (insert) lines do not change shaded areas Expense and Revenue pages can show information for 2 contracts Use separate Schedules A & B to report contracts for each granting State agency Use additional expense and revenue pages for more than 2 contracts copy all lines & fields to the first blank line below the last line in column A with the cursor at the start of the added page, use "insert" "page break" for print purposes reset print range to cover the added page(s) and correct the page numbers Contract Number is the State Contract Number, NOT the agency program number Report by program within the State Contract Number within State Department Summarize programs into totals by State Contract Number and State Department totals Do not combine State Contract Numbers One Funding Information Summary and one Schedule C are required from each contractor submitting reports Review Section C in all contracts for reporting requirements ALLOCATION OF ADMINISTRATIVE COSTS Requires completion of all attached sheets NOTE If files are not properly named and print ranges not set, the report will be returned for correction Do not send invoices with expense reports If refund due, mail reports with check or send note with e-mail that check in the mail e-mail completed files to: Xxxxxx0.XXX.Xxxxxx@xx.xxx e-mail filing replaces mailing forms Mailing Address: Monaliz Hana Telephone 000-000-0000 Tennessee Department of Health Fiscal Services 6th Floor Xxxxxx Xxxxxxx Tower 000 Xxxxx Xxxxxxxxx Parkway Nashville, TN 37243 Attachment 5 PROGRAM EXPENSE REPORT (Excerpted from Policy 3 statement) SCHEDULE A EXPENSE BY OBJECT LINE-I TEMS There are seventeen specific object expense categories; two subtotals (Line 3, Total Personnel Expenses, and Line 19, Total Non-personnel Expenses); and Reimbursable Capital Purchases (Line 20), above Line 21, Total Direct Program Expenses. All expenses should be included in one or more of the specific categories, or in an additional expense category entered under Line 18, Other Non-personnel Expenses. The contracting state state agency may determine these requirements. With the exception of depreciation, everything reported in Lines 1 through 21 must represent an actual cash disbursement or accrual as defined in the Basis For Reporting Expenses/Expenditures section on page 13. THE YEAR-TO-DATE EXPENSES MUST BE TRACABLE TO THE REPORTI NG AGENCY'S GENERAL LEDGER Line 1 Salaries And Wages On this line, enter compensation, fees, salaries, and wages paid to officers, directors, trustees, and employees. An attached schedule may be required showing client wages or other included in the aggregations.