2001-086-RES AUTHORIZING EXECUTION OF CONTRACT CHANGE NOTICE NO 04 (ATTACHMENT NO 01A)

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r INSTRUCTIONS FOR QUARTER!. YIFINAI. FINANCIAL STATUS REPORT FORM 269A (1DH FORM GC-4a) SEC- ENTRY nON I Contractor Name: Legal name of contractor as reflected in the contract attachment 2 TDH Pro~ram: TDH program name as indicated in the contract allachment document -. . 3 Payee Account No.: Account number or other identifying number assigned by the contractor for the'contraetor's internal use. (nol reouired by TDH) 4 Enter the tmique identifying nwnber that has been assigned to the contract allachment. The number normally consists of your agency's 9 digit m.S's Employer lD# plus I digit assigned by TOH and the numb.er ofthwscal y~ar in which the attachment term ends plus a two digit attachment number. (see "Cover PaJ!e 2" OrVal/I' C011rracl document.) 5 Pa)'ee 14 Digit Vendor In No: Number assigned by the State of Texas Comptroller's Office (which a/so incorporales your aJ<ency 's 9 diJ<illRS Emp/oyer ID#) 6 Accounting Basis: Indicate the principal accounting method used by your agency to account for the expenses relating to the contract attachment by placing an "X" in the appropriate space. 7 Pa)'ce: Enter the Payee's complete mailing address. This information must coincide with the State Comptroller's Office records and Vendor ID number in Section 5 above. 8 Contract Term: Enter the beginning and ending date of the contract attachment.(e.g., 9/1/99 - 8/31/00). (See "Cover Paf!e 2'1 oJyourco11lrac{ document.) 9 Period Co,'ered II)' this Report: Enter the beginning and ending dates of the contract quarter covered by this report. (month, day and year) . 10 Final Report: Check "No" for quarterly reports and preliminary "linals" ; check "Yes" for the linal report. (i) Standard Bud2et Cate20ries , (ii) Approved Budget: Approved budget ligures as reflected in the fully executed Contract attachment. The ligures may be changed only by a formal budget amendment. (iii) Project Cost this Period: Contractor's allowable expenditures incurred o.b;,the atta9hment during the quarterly reporting period. (iv) Cumulative Project Cost: Contractor's cumulative allowable expenditures incurred on the attachment from inception through the current Quarterly reporting period. (v) Remainin2 Bud2et Balance: Subtract Cwnulative Project Cost (Column iv) from the aooroved budget (Column ii). k(iii) Program Income Collected: Enter the amount of program income (PI) collected during the quarter. The sum of the program income deducted from the reimbursement vouchers for the quarter should eQual this amount. k(iv) Enter the cwnulative program income collected during the attachment term. This amount should be equal to the total program income deducted from all reimbursement vouchers submitted under the attachment since inception. I(iv) Non-TDH Funding: If the effort for this contract attachment is partially funded by non-TDH sources (from other agencies or with local funds) and all costs of the effort are reflected in the report, enter the cumulative amount of non- TDH funding here. m(iii) Advance Received: Enter the amount of advance payment (if any) your agency has received from TOH. m(iv) Advance Repaid: Enter the cumulative amount of the advance which has been repaid - either by reduction of reimbursement reouest or by refund. m(v) Balance Owed: Subtract the amount of the advance reoaid (m(iv)) from the amount of the advance received. (m(iii)) n(iv) Cumulath'e Rciml.Jursement Requested: Enter the sum of all reimbursement vouche~s submitted for reimbursement of expenditures incurred since the beginning date of the attachment teon. o(iv) Total Reimbursement Receh'cd: Enter the lotal of all cash received for both an advance (if any) and actual cumulative reimbursement navmcnts since the bel!inninl! date of the attachment teon For additional information call the Grants Management PaJ'ments Section@(512) 458-7520. Send Reports to: Texas Department of Health Grants Management Division 1100 West 49th Street Austin. Texas 78756-3199