STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT INFORMATION FORM PAGE 1 OF 20
Agency: Address: Phone: Chief Executive Officer: Prepared By: Date: Agency Federal ID#: Charities Registration #: Non-Profit Agency
For-Profit Agency Public Agency Budget Period:_____________to____________Agency Fiscal Year End:____________ Schedules Completed: 1 2 3 4 5 6 Cash Basis Accrual Basis
Contracting Division
Contract #
Program Name
Reimbursable Ceiling
Type of Service
Contract Type
Payment Method
Division Contact Person
Provider Agency Contact Person and Telephone #
Division Use Only
Contract # Effective Dates_________to___________ Division________________________
Budget: I certify that the cost data used to prepare this contract budget is current, complete, and in accordance with the governing principles for determining costs.
Expenditure Report: I certify that the expenditures reported herein are curent, accurate, and in accordance with the contract budget and the governing principles for determining costs.
Agency Authorized Signatory
Fiscal Officer
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE SUMMARY PAGE 2 OF 20
Agency: Contract#:
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT
INTERIM FISCAL YEAR END FINAL
PERIOD COVERED
1 2 3 4 5 6 7 8 9 10
BUDGET CATEGORY
TOTAL
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
A. PERSONNEL
$ $ $ $ $ $ >>>>>>>>> $ $ $ $ $
$ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $
B. CONSULTANTS AND PROFESSIONAL FEES
C. MATERIALS AND SUPPLIES
D. FACILITY COSTS
E. SPECIFIC ASSISTANCE TO CLIENTS
F. OTHER G. GENERAL & ADMINISTRATIVE COST ALLOCATION H. TOTAL OPERATING COSTS
$ $ $ $ $
I. EQUIPMENT (SCHEDULE 6)
J. TOTAL COST
K. LESS REVENUE (SCHEDULE 2)
L. NET COST
M. PROFIT
N. REIMBURSABLE CEILING
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL PERSONNEL
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Agency: Contract#:
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
A BUDGET CATEGORY: PERSONNEL Position Number Date Hours Employed /Week
10
TOTAL
Position Title/ Name of Employee
1
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
SUBTOTAL(pg. 1)
$ $ $ $ $ $ $ $ $ -
10
11
12
13
14
15
16
17
18
19
20
21
22
23
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL PERSONNEL
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Agency: Contract#:
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
A BUDGET CATEGORY: PERSONNEL Position Number Date Hours Employed /Week
10
TOTAL
Position Title/ Name of Employee
24
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
SUBTOTAL(pg. 2)
$ $ $ $ $ $ $ $ $ -
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL PERSONNEL
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PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
A BUDGET CATEGORY: PERSONNEL Position Number Date Hours Employed /Week
10
TOTAL
Position Title/ Name of Employee
48
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
SUBTOTAL(pg. 3)
$ $ $ $ $ $ $ $ $ -
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL PERSONNEL
6 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
A BUDGET CATEGORY: PERSONNEL Position Number Date Hours Employed /Week
10
TOTAL
Position Title/ Name of Employee
75
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
SUBTOTAL (pg. 4) BUDGET CATEGORY A: EMPLOYEE SUBTOTAL
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ -
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
$ $
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL A. PERSONNEL (FRINGE) PAGE 7 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED 0
BUDGET CATEGORY- A. PERSONNEL-FRINGE LINE ITEM BASIS FOR ALLOCATION
10
TOTAL
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $
FRINGE SUBTOTAL
- $ - $
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ -
$ $
BUDGET CATEGORY A. PERSONNEL TOTAL
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL B. CONSULTANTS AND PROFESSIONAL FEES PAGE 8 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT
PERIOD COVERED BUDGET CATEGORY- B. CONSULTANTS AND PROFESSIONAL FEES LINE ITEM BASIS FOR ALLOCATION
TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ -
UNALLOWABLE COSTS
BUDGET CATEGORY B. TOTAL
10
GENERAL & ADMINISTRATIVE COSTS
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL C. MATERIALS AND SUPPLIES PAGE 9 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
0
BUDGET CATEGORY- C. MATERIALS AND SUPPLIES LINE ITEM BASIS FOR ALLOCATION
10
TOTAL
GENERAL & UNALLOWABLE COSTS ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
BUDGET CATEGORY C. TOTAL
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL D. FACILITY COSTS PAGE 10 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
0
BUDGET CATEGORY D. FACILITY COSTS LINE ITEM BASIS FOR ALLOCATION
10
TOTAL
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
BUDGET CATEGORY D. TOTAL
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL E. SPECIFIC ASSISTANCE PAGE 11 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
0
BUDGET CATEGORY E. SPECIFIC ASSISTANCE TO CLIENTS LINE ITEM BASIS FOR ALLOCATION
10
TOTAL
GENERAL & UNALLOWABLE COSTS ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
BUDGET CATEGORY E. TOTAL
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL F. OTHER
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PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT
PERIOD COVERED
0
9 10
BUDGET CATEGORY F. OTHER LINE ITEM BASIS FOR ALLOCATION
TOTAL
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
SUBTOTAL(pg.1)
$ $ $ $ $ $ $ $ $ -
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL F. OTHER Agency: Contract#:
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PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT
PERIOD COVERED
0
9 10
BUDGET CATEGORY F. OTHER LINE ITEM BASIS FOR ALLOCATION
TOTAL
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
SUBTOTAL(pg. 2) BUDGET CATEGORY F. TOTAL
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ -
$ $
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B: CONTRACT EXPENSE DETAIL G. GENERAL AND ADMINISTRATIVE COST ALLOCATION PAGE 14 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
0
BUDGET CATEGORY G. GENERAL AND ADMINISTRATIVE COST ALLOCATION
10
TOTAL
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
Total: Categories A-F
>>>>>>>>>
General and Administrative Costs
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B SCHEDULE 1-COST ALLOCATION DATA PAGE 15 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
1 ALLOCATION BASE TOTAL
2 0
3 0
4 0
5 0
6 0
7 0
8 0
9 UNALLOWABLE COSTS
10 GENERAL & ADMINISTRATIVE COSTS
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B SCHEDULE 2-REVENUE PAGE 16 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
0
10
DESCRIPTION
TOTAL
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Total K. Revenue
$ $ $ $ $ $ $ $ $ -
Supporting documentation is required to substantiate the allocations.
DHS (REV 7/86)
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B SCHEDULE 3-APPLICABLE CREDITS PAGE 17 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED 0
DESCRIPTION OF CREDIT/INCOME
# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
AMOUNT
TREATMENT (EXPENSE ITEM OR CATEGORY OFFSET)
EXPLANATORY NOTES
DHS (REV 7/86)
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B SCHEDULE 4 - RELATED ORGANIZATION PAGE 18 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED 0
NAME OF RELATED ORGANIZATION
TYPES OF SERVICES, FACILITIES AND/OR SUPPLIES FURNISHED BY THE RELATED ORGANIZATION
EXPLAIN RELATIONSHIP
COST
NAME & COLUMN NUMBER OF PROGRAM/COMPONENT
DHS (REV 7/86)
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B SCHEDULE 5 - DEPRECIATION/USE ALLOWANCE PAGE 19 OF 20
A B C D E F G H I
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
J K
DEPRECIABLE CAPITAL ASSET ITEMS
ACQUISITION COST
EXCLUSIONS
ACCUM. ADJUSTED COST DEPREC. BASIS REPORTED ON (COL B MINUS FINANCIAL COL C) STATEMENTS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
NET BOOK VALUE (COL D MINUS COL E)
ANNUAL DEPREC. REPORTED ON FINANCIAL STATEMENTS -
ANNUAL USE ALLOWANCE
INTEREST EXPENSE
ANNUAL DEPREC. & INTEREST EXPENSE (COL G + I) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ -
ALLOWABLE DEPREC. / USE ALLOWANCE
Agency: Contract#:
STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES ANNEX B SCHEDULE 6-COST OF EQUIPMENT PAGE 20 OF 20
PURPOSE BUDGET PREPARATION MODIFICATION BUDGET EXPENDITURE REPORT PERIOD COVERED
0
9 10
TYPE & DESCRIPTION OF ITEM
BASIS OF ALLOCATION
TOTAL
UNALLOWABLE COSTS
GENERAL & ADMINISTRATIVE COSTS
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
TOTAL OF EQUIPMENT
$ $ $ $ $ $ $ $ $ -
