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Home My WebLink AboutNYS Office of Mental Retardation & Developmental Disabilities NYS Office of Mental Retardation A COUand Developmental Disabilities CHARTING RSE T FOR THE FUTURE �? r LONG ISLAND DEVELOPMENTAL DISABILITIES SERVICE OFFICE THOMAS A. MAUL MARVIN L COLSON Commissioner Director May 25, 1999 Ms. Jean W. Cochran Supervisor Town of Southold 53095 Main Road PO Box 1179 Southold, New York 11971 Dear Ms. Cochran: Enclosed please find the Town of Southold's recently approved 100% Day Training Contract, C013038, Amendment #5. The contract period is January 1, 1999 through December 31, 1999. 1 have also include two vouchers and a CQR report for be copied and submitted for future payments on this contract. If you have any questions, please do not hesitate to contact my office at (516) 493- 1776. Very truly yours, b-in o-.L a Deborah Hammargren Coordinator of Fiscal Services enclosures nl MAY 2 7: 1999 SUPERVISOP,S OFFICE T0wN OF SOU I HOLD 21Lon Island Developmental Disabilities Service Office q ❑ Community Services Office 9 P 45 Mail Drive, Suite 1 a 415-A Oser Avenue Commack, NY 11725-5700 j Hauppauge, New York 11787 (516)493-1700 (516)434-6000 APPENDIX X •• ' AGENCY CODE: 5I0 0 0 CONTRACT NO. : COI3038 Amendment #5 PERIOD: 01/01/99-12/31/99 FUNDING: 18,112 This is an AGREEMENT between the STATE OF NEW YORK, acting by and through the Office of Mental Retardation and Developmental Disabilities (CONTRACTOR) , and Town of Southold for modification of Contract Number C013038 as amended in attached Appendix(ices) B, C, D - All other provisions of said AGREEMENT shall remain in fu-11 force and effect.. IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing under their signatures. CONTRACTOR SIGNATURE: STATE AGENCY SIGNATURE: B w` By: Y� David P. Tupaj Jean W. Cochran Printed Name Printed Name Title• Business Officer Title: _ Supervisor / Q Date: December 11, 1998 Date: -5 / /f 7� State Acrencv Certification: In addition to the acceptance of this contract, I also certify that original copies of this signature page will be attached to all other exact copies of this contract. INDIVIDUAL JORI CORPORATE ACKNOWLEDGEMENT: (select One) STATE OF NEW YORK: ) SS. : COUNTY OF Suffolk ) Individual Acknowledgement: _ before me on this day of 19 personally came to me ]mown and }mown to me to be the in and who executed the within instrument, and he/she duly same person described acknowledged to me that he/she executed the same. Corporate Acknowledgement:: 19 �8 before me on this 11th day of December personally appeared Jean W. o" to me known, who being by me duly sworn, did depose and say that he she resides at BoisSeau AvPmiP of the Southold New York , that he/she is the Suhe/she vervinsG�r corporation described herein which executed the foregoing itrument and that - signed his/her name thereto by order of the board of•directors of said corporation 0T1,TE COMPTROLLER'S SIGNATURE: NOTARY ELIZABETH ANN NEVILLE Signaturg/ ate 9 Notary Public,State of New York ` �� No.52-8125850,Suffolk County Term Expires October 31,avc - 1 (Please Affix Stamp) Re,,. 1/25/96 REGEIVE0 OMRDO r r 99 APR - 2 AN 10: 42 Y an' NEW YORK STATE SCHEDULE CFR-i CONSOLIDATED FISCAL REPORT AGENCY IDENTIFICATION For the Period: January 1, 1999 to December 31, 1999 AND CERTIFICATION STATEMENT BUDGET AGENCY NAME: Town of Southold AGENCY CODE: 8703910 NOT-FOR-PROFIT: AGENCY ADDRESS: 53095 Main Road P.O. Box 1179 COUNTY NAME: Suffolk PROPRIETARY: Southold NY 11971-0959 COUNTY CODE: 052 GOVERNMENTAL: _ Person to Contact with Regard to Questions Concerning this Report: CHECK THE STATE AGENCY(IES): OMH OMRDD x _ John CuslLan (516) 765-4133 OASAS *a Name Telephone Number Town Comptroller (516)765-1366 SUBMISSION TYPE: BUDGET Title FAX Number 12/11/98 Date Prepared Rev. 01-May-97 CFR-i Please Check State Agency: NEW YORK STATE SCHEDULE CFR-a OMH CONSOLIDATED FISCAL REPORT PERSONAL _OMRDD For the Period: January 1, 1999 to December 31, 1999 SERVICES 0ASAS BUDGET page i AGENCY NAME: Town of Southold REPORT FTE'S TO 2 DECIMAL PLACES. AGENCY CODE: 8703910 USE WHOLE DOLLARS. BUDGE T USE WHOLE HOURS. Provide all applicable Information. Refer to Appendix R for Position Title Codes and Definitions. Check the standard work week or provide the number of hours In the "other" column. Check the staffing category to which each page applies: PROGRAM/SITE-PROGRAM ADMIN./LGU ADMIN. Position Title Codes 100-590 and 700 series AGENCY ADMINISTRATION Position Title Codes 600 series Position COLUMN NUMBER A Title Code PROGRAM CODE 0330 Appendix PROG/SITE ID. R Standard Hours Amount Hours Amount Hours Amount Hours Amount Hours Amount Position Title Work Week Paid FTE Paid Paid FTE Paid Paid FTE Paid Paid FTE Paid Paid FTE Paid 35 37.5 40 Other 309 ro ram ulezv: : X 1 ,000 i Tola!"FTE" and "Amount Paid" for Positions. .33 14 Transfer totals to Schedule CFR-1 Line 16(Program/Site &Program Administration), or Schedule CFR-3 Line 1 (Agency Administration).Report Agency Agency Administration in one column on a separate page. Rev. 01-May-9. Note: FTE's do not get transferred. Keep program columns consistent throughout the CFR document. Please Check State Agency: NEW YORK STATE SCHEDULE DMH-2 OMH CONSOLIDATED FISCAL REPORT AID TO LOCALITIES/ R OMRDD For the Period:January 1, 1999 to December 31, 1999 DIRECT CONTRACT SUMMARY OASAS BUDGET Page 2 AGENCY NAME: Town. of=Southold COUNTY NAME&CODE: SuffolkO( 52 1 AGENCY CODE: 8703910 PREPARED BY: John Cushman BUDGE T DATE PREPARED: 12/11/98 TELEPHONE: 516 765-4193 USE WHOLE DOLLARS. Line COLUMN NUMBER Cost A No. ITEM DESCRIPTION Codes 1 Accounting Method odified Accrual 2 Contract Number 00200 C013038 3 Program Type 00010 Day Training 4 Program Code 00010 0330 EXPENSES 5 Personal Services 18010 14,000 6 Vacation Leave Accruals 18020 7 Fringe Benefits 18030 1,080 8 Other Than Personal Services 18040 9 Equipment-Provider Paid 18050 10 Property-Provider Paid 18060 11 Agency Administration 18080 3,250 12 Adjustments/Non-Allowable Costs 18090 13 Total Adjusted Expenses(Lines 5-11 minus 12) 18999 18.330 REVENUES 14 Participant Fees(less SSI &SSA) 46010 15 SSI &SSA 46020 16 Home Relief 46030 17 Medicaid Regular 46040 18 1 Medicare 46060 19 Other Third Parties 46070 20 OMRDD Residential Room and Board 46080 21 Transportation, Medicaid 46090 22 Transportation, Other 46100 H24 Sales: Contract Total 46140 Federal Grants(Attach detail) 46160 _ DMH-2.1 Rev. 01-May-97 Please Check state Agency: NEW YORK STATE SCHEDULE DMH-2 ZUMH CONSOLIDATED FISCAL REPORT AID TO LOCALITIES/ _ x OMRDD For the Period: January 1, 1999 to December 31, 1999 DIRECT CONTRACT SUMMARY OASAS Page�_ BUDGET AGENCY NAME: Town-of Soutbol d COUNTY NAME&CODE: $j,ffr.11r AGENCY CODE: 8703910 PREPARED BY: Tnbn r„cbTnnn BUDGE T DATE PREPARED: 12/11/98 TELEPHONE:(516 765-4333 USE WHOLE DOLLARS. COLUMN NUMBER ost A Line ITEM DESCRIPTION Codes No. Program Type 00070 Program Code 00010 0-330 25 State Grants(Attach detail) 46190 26 LTSE Income Total 46220 27 Food Stamps(OASAS Only) 28 Net Deficit Funding (State & LGU Funding only)' 46110 8,112 29 Other Revenue 46230 30 Total Gross Revenue (Sum Lines 14-29) 46999 8,112 GAAP ADJUSTMENTS TO REVENUE 31 Participant Allowance 47010 32 Uncollecuble Accounts Receivable 47040 33 Other(Attach detail if>$1,000) 47045 34 Total GAAP Adjustments(Sum Lines 31-33) 47049 35 Net GAAP Revenues(Line 30 minus 34) NON-GAAP ADJUSTMENTS TO REVENUE 36 Exempt Contract Income 47050 37 Exempt LTSE Income 47060 38 Net Deficit Funding'* 47070 39 Other(Attach detail if>$1,000) 47080 40 Total NON-GAAP Adjustments(Sum Lines 36-39) 47998 M8,112 41 Subtotal Adj. to Revenue (Sum Lines 34 &40) 47999 42 Total Net Revenues(Lines 30 minus 41) 48999 43 Net Operating Costs(Line 13 minus 42) 49999 1 , DEFICIT FUNDING 44 State 60010 , 45 Local Government 60020 46 Voluntary ontributions 60030 47 Non-Funded 60040 _L8_:Total Deficit Funding(Sum Lines 44-47) 60999 O DMH-2.2 ® Do not include non-funded or voluntary contributions. Rev. 01-May-97 Amounts should equal the corresponding amounts reported as revenue. NEW YORK STATE SCHEDULE DMH-2A Please Check State Agency: AID TO LOCALITIES/ _ X OMRDD CONSOLIDATED FISCAL REPORT DeDIRECT CONTRACT RY OASAS For the Period: January 1, 1999 to cember 31, 1999EQUIPMENTSUMMA BUDGET Page--L- AGENCY am4AGENCY NAME: Tnwn of Snnthnl if BUDGET f AGENCY CODE: 8703910 LINE COLUMN NUMBER A NO. ITEM DESCRIPTION 1 PROGRAM TYPE Dgy Tra' ting 2 PROGRAM CODE 0330 EQUIPMENT>$2,500(LIST INDIVIDUALLY) 3 None 4 5 - 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 EQUIPMENT<$2,500 EACH(AGGREGATE TOTAL) 24 TOTAL EQUIPMENT DMH-2A Note: Do not include any expensed equipment reported in the OTPS line on this schedule. - Rev. 01-May-97 NEVA YORK STATE SCHEDULE DMH-3 Please Check State Agency: AID TO LOCALITIES AND DIRECT CONTRACTS OMH CONSOLIDATED FISCAL REPORT PROGRAM FUNDING SOURCE SUMMARY _x OMRDD For the Period: January 1, 1999 to December 31, 1999 OASAS BUDGET Page �� AGENCY NAME: Town of Southold COUNTY NAME&CODE: Suffolk (092-) BUDGET AGENCY CODE: 8703910 DATE PREPARED: 12/11 /98 USE WHOLE DOLLARS. TOTAL Line COLUMN NUMBER Cost A=. No. ITEM DESCRIPTION Codes 1 1 Accounting Method Modified Accrual 2 Program Type 00070 Day Tra l in 3 Program Code 00010 03 00220 2 2 4 Total Persons Served/Month 5 Total Units of Service 00999 952 6 Gross Cost/Unit of Service 70999 19.25 7 Net Cost/Unit of Service 1 71999 19.2 PARTICIPANT SPECIFIC METHODOLOGY 8 Please Check: ( % )NON-PARTICIPANT SPECIFIC METHODOOLOOGY ( 001 001 9 IA. Funding Source Code(Local Assistance) Index(OMH only) 001 001 10-1 Number Persons Served/Month 00260 11 Number Units of Service 00250 12 Total Adjusted Expenses 50999 13 Less Applied Net Revenue 61999 14 Net Operating Costs 62999 15 Contract Number 00200 16 B. Funding Source Code Index(OMH only) 022 17 Number Persons Served/Month 00260 18 Number Units of Service 00250 19 1 Total Adjusted Expenses 50999 8,112 20 Less Applied Net Revenue 61999 8.112 21 Net Operating Costs 62999 22 Contract Number 00200 C013038 23 C. Funding Source Code Index(OMH only) 099 24 Number Persons Served/Month 00260 25 Number Units of Service 00250 26 1 Total Adjusted Expenses 50999 10,218 27 Less Applied Net Revenue 61999 28 Net Operating Costs 62999 10,218 29 Contract Number 00200 0. Totals From A-C Above 30 Total Adjusted Expenses 51999 18,330 31 Less Net Revenue 63999 1 8 1 3 Net Operating Costs 52999 1 10,218 DMH-3 Rev. 01-May-97 �-,: . / �j�� ''�� py 4G ne2 �r� � ?� lvJ �� fit':&', �.. _ 1� 9 APPENDIX C C013038 Amendment #5, - LONG ISLAND — Developmental_ Disabilities Services Office Contract and Amendment Numbers Payment and Reporting Schedule for Period 01/01/99 to 12/31/99 CONTRACTOR Name: Town of Southold -_ — Fill in all the blanks for human services operating contracts. Fill in all the blanks except the ones outlined in bold for non—operating contracts. To receive payment the CONTRACTOR must submit reports as required by the OMRDD. Payments will be adjusted by the OMRDD to reflect only those services/expenditures" that were made in accordance with this Contract. Submit New York State Vouchers with supporting documentation to: Long Island DDSO - c/o Deborah Hammargren 45 Mall Drive Commack, New York 11725 Part C-1 -- PAYMENTS DATES OE DUE DATE AMOUNT CONDITIONS SERVIFirst Advance 01/01/99-03/31/99 01/01/99 S 2,028 2,028 Second Advance 04/01/99-06/30/99 04/01/99 $ — 07/01/99-09/30/99S � First Report Interim .-- 10/01/99-12/31/99 10/01/99 S 1,217 Second Report Interim -- — S Other $ Confirmation Other Available BALANCE End Reports* Final TOTAL $ 89112 Approval of OPTIONAL S 2,028 — Continued Fundin TOTAL+ OPTIONAL $ 10,140 *This payment shall be preceded by an additional thirty(30)calendar day period for the purpose of an audit of the End Reports,as provided hi Section 179—f(2)(b)of the State Finance Law. **At least one must be circled,i.e.services and/or expenditures. . Part C-::-2j ' APPENDIX C for: HOMECARE, CLINIC TREATAfENT FACILITY, and SOlt_:F DAY-TRA31-TIN`s CONTRACTS (ONLY): - On a monthly basis,the CONTRACTOR rha'1 submit timcly app:opriate,and P►'�;:::lY co=pietad:•:ew York State - vouchers to request reimbursement und:r this CONTRACT,in :ccot:ance with i s t=s 7,ecified in AppenZ�:D not to axe:ed the total payments specified in Appendix B.These vouchers shall have anncxei'.suc'.l st:prortittg docum:^.ts as the OMRLII: may require,in a form prescribed by the OMRDD. — G/2/95 . h C • C013038 Amendment 15 LONG ISLAND APPENDIX D Concoct aad Amendment Plumbers The Plan Summary for Period D • cvclopmcaW Disabilie=s Services Office 01/01/99 to 12/31/99 Town of Southold CONTRACTOR Name: . Phone #: ( 516• ) 765-4333 Site Address: FaX #:• 516 765-1366 5.3095 Main Road Count : Southold, NY 11971-0959 Target Number to be Served: Tar et Group(s)' 2 Developmentally disabled senior adults. a o so ou la nd recredetipnol uni1vetl��raoulr o e mg nasg n he �ei`rn156:1 es e�m, Uu11 er -conri�ence an yen er as e en lance par lclpfaaccom lishment. Primar Service(s): sense o ISecondar Service activities : We provide an- array of social and recreational Summar Y The in order to provide a meaningful day of programming. basic program is enhanced by field trips within our community such as icnics tri s to the e � tial We provide special visits to our local points of interest. l celebrations such as individual birthday and'holiday parties. - � ets from our guests for demonstrations, We invite g gardening . I local animal shelter and s Bakers from various communit I a encies. ' I 11 - - -- IS�LC'S iS _. Attach xddic0r_1 '�srtzres lI •, . r �� „ilia 1� �il �''teJ /� �e