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INSTRUCTIONS FOR QUARTERLY/FINAL FINANCIAL STATUS REPORT FORM 269A (TDH FORM OC-4a) SEC- ENTRY TION I Contractor Name: Legal name of contractor as reflected in the contract attachment 2 TDI[ Program: TDH program name as indicated in the contract attachment document 3 Payee Account No.: Account number or other identifying number assigned by the contractor for the contractor's internal use. (not required by TDH) 4 Enter the unique identifying number that has been assigned to the contract attachment. The number normally consists of your agency's 9 digit IRS's Employer ID//plus 1 digit assigned by TDH and the numbgr of tJte..fiscal y_ear in which the attachment term ends plus a twodigit attachment number. (see "CoverPage2"ofyourcot~tractdocument.) 5 Payee 14 Diglt Vendor ID No: Number assigned by the State of Texas Comptroller's Office (which also incor?orates your agency ~ 9 digit IRS Em?loyer ID#) 6 Accounting Basis: Indicate the principal accounting method used by your agency to account for the expenses relating to the contract attactunent by placing an "X" in the appropriate space. 7 ! Payee: Enter the Payee's complete mailing address, This information must coincide with the State Comptroller's Office recerds and Vendor ID number in Section 5 above. 8 Contract Term: Enterthebe~mningandendingdateofthecontractattachment.(e.g.,9/l/99-S/3t/OO).(See "Cover , Page 2" of your contract document.) 9 ~ Per[od Covered by tills 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, "finals"; check "Yes" for the final report. (i) Standard Budget Categories (ii) Approved Budget: Approved budget figures as reflected in the fully executed'contract attachment. The figures may be changed only by a formal budget amendment. (iii) Project Cost this Period: Contractor's allowable expenditures incurred o~ the attaghment during the quarterly reporting period. (iv) Cumulative Project Cost: Contractor's cumulative allowable expenditures incurred on the attaclunent from inception through the current quarterly reporting period. (v) Remaining Budget Balance: Subtract Cumulative Project Cost (Column iv) from the approved budget (Column ii). k(iii) Program Income Collected: Enter the amount of program income (PI) collected during the quarter. The sum of the proFram income deducted from the reimbursement vouchers for the quarter should equal this amount. k(iv) Eater the cumulative program income collected during the attachment term. This amount should be equal to the total pro.am income deducted from all reimbursement vouchers submitted under the attaelunent since inception. l(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. re(iii) Advance Received: Enter the amount of advance payment (if any) your agency has received from TDH. m(iv) Advance Repaid: Enter the cumulative amount of the advance which has been repaid - either by reduction of reimbursement request or by refund. re(v) Balance Chved: Subtract the amount of the advance repaid (m(iv)) from the amount of the advance received. (m(iii)) ri(iv) Cumulative Reimbursement Requested: Enter the sum of all reimbursement vouchers submitted for reimbursement of expenditures incurred since the be,sinning date of the attachment term o(iv) Total Reimbursement Received: Enter the total of all cash received for both an advance (if any) and actual cumulative re/mbm'sement payments since the beginning date of the attachment term For additional information call the Grants Management Payntents Section (~ (512) 458-7520. Send Reports to: Texas Department of Health Grants Menagement Division 1100 West 49th Street Austin, Texas 78756-3199