ࡱ> rq Fɀ\pjdecolan of Mental Health Ba=   =xx-8X@"1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Helv1Helv1Arial1Helv"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)                + ) , *   #0  @@  @   @ #0@    #0@   @   `  #p  "0@  @  ` #0 #p "0 @ #0   $ % $   $  (@  (  ( "0  (@ "8@  ( @  $  (@  (@  h@  @@  @ #8@  ( @ "8@ "8 @  !@ @  !@ "8!@ "8! @  $!@  $! @ "8@@   @  $@  $ @   @  $@  ,@  d@  ( @  !    ! #  ! " ! " ! "   !   "        ` #  `   !  $  $  $   $  d@  l@ % $@ % $@ % $ @  $ " "0 @ "0      `  `  "8@ "0    !    @   #0 !p !x !x !0  !8  !0 #0@ #0@ #0@@  @@  `@ #0@  @ @ #0@ #0@  @  @  `   @ " "  "8  "8 "0@@ "0@ "0  @ "0@ "0 "0  "8@@  "8@  "8  @ "8 "8@ "8  l  $ "8@@ "8@ "8  @ `#2Table of Contents9 A-AllocationsMI B-RelatedOrgs(U C-RentalsbD-Depreciationu E-Equipment F-Ethnicity ՒGܓ H-Housing I-Interest Definitions 8    ;,   ;+  ;-  ;4  ;2  ;0  ;0  ;-   ;T#v4STATE OF NEW JERSEY - DEPARTMENT OF HUMAN SERVICES"DIVISION OF MENTAL HEALTH SERVICES/SCHEDULE A : STATISTICAL ALLOCATION BASESProvider Agency:Agency Address:Contract Number:Contract Period:SquareFootage(%)StaffFTEsProgramTOTALS:General & Administrative Unallowable&SCHEDULE B : RELATED ORGANIZATIONSIPLEASE LIST AND EXPLAIN ALL RELATIONSHIPS WITH RELATED COMPANIES, SUCH AS THOSE WITH COMMON BOARD MEMBERS.GFOUNDATIONS, SUBSIDIARIES, HOLDING COMPANIES, SISTER CORPORATIONS, AND Nature of Relationship:Related Company:Explain financial transactions between companies for staff, services, facilities, etc.:$SCHEDULE E : EQUIPMENT PURCHASESKEQUIPMENT IS DEFINED AS AN ITEM OF NONEXPENDABLE TANGIBLE PERSONAL PROPERTYMORE PER UNIT.NDHS MAINTAINS AN EQUITY INTEREST IN ALL EQUIPMENT PURCHASED VIA THIS CONTRACT,UNLESS SPECIFICALLY NOTED.NFOR MORE INFORMATION, REFER TO DHS CONTRACT POLICY P4.05 - CONTRACT EQUIPMENT.Description of ItemsQuantityContractUsefulTotalCost Life (Yrs)TOTAL:Contract Period: Contract Number: Agency Address: Provider Agency: ,SCHEDULE C : RENTAL OF SPACE & EQUIPMENTDescription of Items RentedLessorAnnualRentalPaymentsCosts Allocable to Contract Basis for Allocation)A. Buildings & Land (include addresses)Totals: B. Equipment[STATE OF NEW JERSEY - DEPARTMENT OF HUMAN SERVICES - DIVISION OF MENTAL HEALTH SERVICESDSCHEDULE OF CONTRACT-RELATED DEPRECIATION CHARGES FOR CAPITAL ASSETS&AGENCY: _____________________________CONTRACT: ____________+PERIOD COVERED: __________________________[ ] BUDGET PREPARATION EXPENDITURE REPORTINGDEPRECIATION EXPENSE:ABCDEFGHIJKLCapital Asset Items: Acquisition Exclusions: Exclusions asAdjusted Depreciable AccumulatedPercent Contract-!Buildings, Building Improvements,Date Any Level of a Percent ofBasis DepreciationUtilized AllowableLand Improvements, Equipment (minus land) (Month/Year) Govt. Subsidy(B - D) (number of Reported onBy DMHS (sq. feet,$(please specify items, and addresses Cost (D / B)years) FinancialPrograms # of staff,Expense for buildings) Statementsetc.)(100%-E) x I x JTOTALS: CONTRACT: AGENCY:  PERIOD COVERED: Capacity(Beds)Agency-Owned(x)Leasedof CareAverageMonthly Rent Paid by ClientRental Total ContractIncome (all clients)@SCHEDULE OF CONTRACT-RELATED INTEREST CHARGES FOR CAPITAL ASSETSINTEREST EXPENSE: Financing CumulativeCurrentLoan Interest PrincipalLoanof AssetAmountRatePaidBalance(B - F)(sq. ft., # of staff, etc.) (H x I)8DEPARTMENT OF HUMAN SERVICES CONTRACT POLICY DEFINITIONSAcquisition Cost: 2The net price of an item of equipment, or tangible3property, including the cost of any modifications, /attachments, accessories or auxiliary apparatus5necessary to make it usable for the purpose for whichit was acquired.Contract-Allowable Expense:1The portion of the acquisition cost, depreciation0expense, interest expense, or use allowance that5DHS may include in its contract budgets / expenditure6reports, for the contract period, after exclusions and1non-DHS uses are eliminated from the calculation.1Refer to the DHS Contract Reimbursement Manual - "Section 4.6, p.12 for more detail.Depreciation &3The decline in value associated with capital assetsDepreciation Expense:5over a period of time due to normal wear and tear and2deterioration. Depreciation Expense is the annual6calculation used for allocating the expired cost of an3asset (e.g., buildings, office equipment, computer 2equipment), less salvage value, over its estimated0useful life in a rational and systematic manner. Equipment:-An article of nonexpendable tangible personal5property having a useful life of more than two years,Estimated Useful Life:2The number of years that an acquired capital asset5is expected to remain functional, after which time itmay need to be replaced.0[Note: DHS will generally accept the accounting2industry's guidelines, as interpreted by CPAs, in 5establishing the useful life of a capital asset; but,1DHS reserves the right to restrict its financial 2support for the depreciation of an asset when the 'useful life is deemed to be too short.]3In this context, a Cost or portion of Cost which is+eliminated or omitted from the DHS Contract0Budget. Refer to the DHS Contract Reimbursement3Manual - Section 4.6, p.7 for details on exclusions+for Depreciation and Use Allowance charges.Use Allowance:6For fully-depreciated assets, the Use Allowance is the0DHS contract-allowable expense, less exclusions,0for facilities or equipment which continue to be1utilized by DHS-contracted programs. The expense,for equipment is calculated at 6.67% of the /Acquisition Cost; the expense for facilities is)calculated at 2% of the Acquisition Cost.!N.J. DEPARTMENT OF HUMAN SERVICES8SCHEDULES FOR USE WITH BUDGETS & REPORTS OF EXPENDITURESWorksheet Tab in File Schedule TypePaper Size & OrientationA - AllocationsB - RelatedOrgsStatistical Allocation BasesLetter (portrait)Related Organizations C - RentalsRental of Space & EquipmentLetter (landscape)D - DepreciationDepreciation ExpensesLegal (landscape) E - EquipmentEquipment Purchases F - EthnicityStaff Ethnicity(unused) H - HousingClient Housing I - InterestInterest Expenses DefinitionsFiscal Terms Defined3and an Acquisition Cost of $5,000 or more per unit.VTOTAL OF CONTRACT-ALLOWABLE INTEREST EXPENSE MUST BE RECORDED IN SECTION D ON ANNEX B.PHAVING A USEFUL LIFE OF MORE THAN 2 YEARS, AND AN ACQUISITION VALUE OF $5,000 ORZTOTAL OF CONTRACT-ALLOWABLE DEPRECIATION EXPENSE MUST BE RECORDED IN SECTION D ON ANNEX B.XNOTE: TOTAL CONTRACT-ALLOCABLE RENTAL EXPENSE MUST BE RECORDED IN SECTION D ON ANNEX B.#SCHEDULE F : ETHNICITY OF STAFFSTAFFPOSITIONNUMBER ETHNICITYCODEAFOR ALL AGENCY EMPLOYEES INCLUDED ON THE CONTRACT BUDGET, PLEASE CRECORD THE STAFF POSITION NUMBERS AND THE CODE FOR THEIR ETHNICITY: Provider Agency: Agency Address: Contract Number: Contract Period:% 4 = Hawaiian or Pacific Islander 5 = Hispanic Origin 6 = White* 1 = American Indian or Alaskan Native 2 = Asian 3 = BlackM[Group homes, apartments, and family care homes utilized for client housing] Type (GH, Apt)Housing Units, by County and Level$[use Licensing Code and City / Town,no street addresses] (A+, A, B,C, D)&SCHEDULE H: CLIENT HOUSING SCHEDULE  4J]s'Nd?U+A   l! 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