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HomeMy WebLinkAboutSC Cntr Agency Disclosure FormsKAREN McLAUGHLIN Town Director of Human Services Town of SouthoM 750 Pacific Stxeet P.O. Box 85 Mattituck, NY 11952 Tel. (631) 298-4460 Fax (631) 298-4462 Nutrition Program Home Delivered Meals Case Managemem Essential Transportation Senior Adult Day Care Alzheimer's Day Care Telephone Reassurance Residential Repair MEMO To: Elizabeth E. Neville, Town Clerk From: Karen McLaughlin, Director ,.~i::.f4,._.~ - Re: Suffolk County Contract Agency Disclosure Forms Date: 8/9/05 Attached please find a copy of the disclosure forms for Suffolk County contracts for 2004. John Cushman recommended a copy be sent to you to keep on file. I will also retain a copy in my files at the Human Resource Center. Thank you. COUNTY OF SUFFOLK OFFICE OF THE COUNTY COMPTROLLER JOSEPH SAWICKI, JR. Comptroller July 18, 2005 Mr. Joshua Horton Supervisor Town of Southold 53095 Main Rd., PO Box 1179 Southold, NY 11971 Dear Mr. Horton, In accordance with Suffolk County Local Law No. 9-2001, "A Charter Law To Require Annual Expenditure Disclosure For Contract Agency Funding," your agency is required to complete the attached Contract Agency Disclosure Form(s). Instructions for the completion of the form are attached for your convenience. If you have any questions regarding its completion, please contact Scott Rasmuson, Auditor (63 l) 852-2061. Each form includes agency and program data that was entered based on Information provided by the County department responsible for the oversight of your contract. A separate form should be completed for each program~administered by your agency for Suffolk County. If you are missing a form for a particular program/contract, please contact Scoa Rasmuson for further instructions. Please complete and return the disclosure form(s), as well as a copy of .','our agency's audited 2004 financial statements to the following address, no later than August l? 2005. Richard Caggiano Contract Compliance Unit Room S-232 Evans K. Griffing Building 300 Center Drive Riverhead, NY 11901 Failure to comply with this request may result in a recommendation to eliminate funding for your program(s) in the County's 2006 operating budget. Thank you for your anticipated cooperation. Very truly yours, Richard Caggiano Con~act Compliance Unit Office otthe Comptroller H. LEE DENNISON BUILDING · 100 VETERANS MEMORIAL HIGH~'AY * P.O. BOX 6100 * HAU~ADGE, NY 11788-0099 (631) 853-8040 Fax (631) 853-5057 KAREN MCLAUGHLIN Town Director of Human Services Town of Southold 750 Pacific Street P.O. Box 85 Mattituck, NY 11952 Tel. (63 I) 2984460 Fax (63 I} 298-4462 Nultition Program Home Delivered Meals Case Management Essential Transportation Senior Adult Day Care Alzhcimer's Day Care Telephone Reassurance Residential Repair August 8, 2005 Richard Caggiano Contract Compliance Unit Room S-232 Evans K. Griff'mg Building 300 Center Drive Riverhead, N.Y. 11901 Dear Mr. Caggiano, Enclosed please find the completed Contract Agency Disclosure Forms for the CSE Residential Repair, IH C Nutrition, Supplemental Nutrition Assistance and Youth Programs for the Town of Southold. I have not included the Town's audited financial statements for 2004 as they are not yet completed. Our Town Comptroller, John Cushman, informed me that once the statements are completed we would gladly forward them to you. In closing, if you have any questions or need further information regarding the enclosed disclosure forms, please contact me at 2984460 or call John Cushman, Town Comptroller at 765-4333. We would be happy to assist you. cc: John Cushman, Town Comptroller Elizabeth Neville, Town Clerk · Contr61Numbe [~ ,. ?suedo Code [ Page 2 of 4 Revenue Note: Numbe'~s 9 tlirough 19repmS%t revenue data ii · Transmitted Percentage speeifi~e t0. the progmTM being repo~tey:l. Number 20 I Retained In Full to · Transmitted represent~allrevenuer%eivedby'yoUragencyintotal ~ ' : by [from all sbUrees: ' ' ~.: i-..'.' ' :~ 2004 Actual' 2005 Estimated Agency? county? · C0un~..'? 9)TotalRevenu, eReceivedf~°msuff°lkC°untyI 57,878.00 1'57,878.00 ' · · · ~'~ -) -:· "":::"~L ~) " " ' ' ~' " ::": · ' ' ' ..... ' ' ' ' ...... [] !0)State. AidRe~ei ed t .A en i:.i - · _ ~.- o 10a) If State Aid is Received; ~ . When does the grant eXpire?: [' 11) Federal Aid Received'Directly by Agency I 11 a)If Federal Aid is Received.. :_. When does the 'grant eXpire? t I2) Aid / Grant~ fro~ Other Municipalities/Agencies] o ] o [] 12a) Identify Other Aid Sources Various 13) Medicare Revenue 14) Medicaid Revenue 15) Third Pan~. Insuarance R~venue: 16) SelfPa~ Revenue' · . ]7) Fund Raising Rev6nue 18) Other Sources of Kevenue 18a)~,Identify .0 ,ther So,ecs 6f Revenu 19) Total Program Revenue · 124,614.00 I 4o,59o.oo , 0 ' "i "o ' [] [] Clio % [] :' [] ,:'::: :: [].1 o-i"''° [] ,~.,' :' []fo % [] El' E3lo % ]82'492.00 [ 98,378.00 20) Total Agency Revenue 12~, 344,01 6.~6/ 28,102,995.25 Control Number [ '5>fi&. Psuedo Code Expenses Direct Program Expenses 21) Direct Salaries (Full and Part Time). (* See No~e) 22) Direct Fringe Benefits 23) Fee for Service : 24) Direct Other than Pemormel Services !. 25) Total Direct Program Expense (Add Lines 21 through 24) Administrative Expenses 26) Administrative ~alaries (Full and Part Time)(* See Note) 27) Administrative Fringe Benefits 28) Administrative Other than Personnel Services 29) Other Adbainistrative Costs 2004 Actual e/A please 2004 Actual' 30) Total Administrative Expenses (Add Lines 26 tlxrough 29) [ 31) Total Gross Program Expenses (Add Lines 25 and 30) [ 32) Less: Offsetting Revenue [ 33) Less: Anticipated Savings, if applicable [ Page 3 of 4 34) Net Contract Amount (Equals Line 31 less Line 32 less Line 33) 35) if not calendar year, !ndicate fiscal'year [ 36) Is'your agency affiliated with any other corporations ? (Yes/No) 37) If yes, name corporation(s), and explain your agency's affiliation. 2005 Estimated [ see at[ached 2005 Estimated I 38) Are any program expenses paid directly by the County? (Yes / No) 39) If so, identify expenses paid by County NO *Note: If an amount is entered in Line 21 (Direct Salaries) then the corresponding Top 5 individual salaries must be entered on page 4 Line 40. Additionally, if an amount is entered in Line 26 (Administrative Salaries) then the Suffolk County Agency Contract Disclosure CONTRACTOR NAME: CONTRACT: Town of Southold III C Nutrition Reference: Page 3, questions 21 through 37 Program expenses are recorded pursuant to rules and regulations promululgated by GASB and the New York State Comptroller and are not segregated by County program. Therefore, this program specific information is not available. Comdl'~um~r [ 7 3 2 Psuedo Code [ ,:. . . Salary Information TOP 5D~rect!Program Salaries " .... '.. ' ' · · ': · Salary Amount Page 4 of 4 .. % of Total . -.: : , Salary ¢l/a~g~d Public Charged to to p[ogram . Disclogure 'Nme / Titl? : _ 2004 ~'oiat S~!~ry'.."f Program Form?- .1) ].The.rest ~;anEtten I 4 ,320.47 ]See Attachment :':. "l~ ....... '-'-'~ ........ ""'.-,........ · ::'..;' ,,, :....:'-:~.-:::'....':'%.,' ': ~.;.,-~.~r~ior.:.Center Mgr,.i :: ~7.'',~, ~":' ..'; -:' ;.' ,...:-' : j;'.~}:.':i.~."..,.. :,~. '. ..... '2):l.~Tane Edstro.m [40,409.92 . /!See Att.achmenfi~';'t '[ Senior Clerk Typist 3) !v.a~e~ie Maione [ 37,461.15 [See Attachment [ % [] I Cook 4) J..Cher. vl.Kas~ell .... [ 33,893.86 . See Attachment-.-[ % [] Account Clrk Typist 5) I Joanna Johnson .I 28,152.28 tSee Attachment %' [] Senior Ci. tizen Aide 41) Top 5 'Agency Sa aries .~artin Flatley_,, 14], 44.38 0 0 % ]Police Captain 2) ]'Carlisle Cochran [ ~37,943.44 0 I' 0 % [] ]"'P'olice Chief , . . . . 3) [F, r2nk Krus.zeski . } 13.6,811.15 'l 0 "] 0 ]Police Lieutenant '" ' ' ' ' ' :· ) l john Sinnin~ I ' [ '- .... ~ .... 3 ,656.2 · 0 ' .[.Oeec. Sgt. , '.., ' "' . . 5). ], ames Gina 133,553.09 I 0 ]'0 ] Police Lt. " .Form Prepared By Title · - Phone Number I John Cushman I Town Comptroller ~631 )765-4333 -Agency Program Contact Title Phone Number [ Karen McLaughlin [ Dir. of Human Svcs. ~631)298-4460 I certify that the data proviCed is true ami accurate to the best of my knowledge: si~,,~,,, .,a o.,, [ ,-~-'"' ~ ~ ~__~.,w~,,T,,, I~aren McLaughlin, Dir' Control Numbe [ -7 7 ! ' Psuedo Code I .Page 2 of 4 · ReVenUe N~ie:'Nfimb~'rs 9 through 19'representrevenue'dam '/ . · ' . .: ~ Transmitted perqentage Ispecmc to the program being reported. Number 20 I - - ~, . ~tamed In F~i!I~? .'?[~a.~i~ed: representsallre~,enuereceP, ed by ~our agency m total ] :~nn~ X~.~ ::~nn~C~+:~,;+~a Y Suffolk'. toSuff0i~ : [~rom, an sources .... .. ! g ~ t County? :' County9.:: 9),Total Revenue Receivedfrom Suffolk County ~ 5 8 3 2 6.2 0 1~ 2 9,3 5 2 0 0 10) State AidReceiv~d Directly'by A~e~lcy :.I ] "' 0 0 10a) If State Aid is Received, When does the grant expire? J' ' 1 l) Federal Aid Received Directly by Agency 1 la)If Federal Aid is Received Whendoes the grant exPire?. I2) Aid / Grants fr0iii Other Municipalities/Agencies I o I o [] [] 12a) Identify Other Aid Sources 13) Medicare Revenue 14) Medicaid Revenue '1'5) :Third Party lnsuaranc~'.R~venue 16) 'Self Pay Revenue 17) Fund Raising' Revenue :~ 18) Other Sources of Revenue ' [ 0 I 0 I ga~ Identify O[~her So~,ees' of~Reve,n.u,. [] [] IDJo ~ [] . '.".'. []1.o~ ih [] [] ': []1 o % [] [] ' []Jo % 19) Total Program Revenue 20) Total Agency Revenue ~19,013.20 [209,352.00 ~8,344,016.i6/ 28,102,995.25 Control Number Psuedo Code Page 3 ~f 4 · . .. · Expenses Direct Program ExPenses i ,,. i;i : ' ' ' 21 ) Direct Salaries (Fuil · :22) Direct Fringe 25) T~ial'Dir&i Program Expense 2004 Actual N/A PLEASE SEE 2005 Estimated N/A 'Administrative Expenses ' . 7.. -: · 2004 Actual-. - 2005 Estimated' · .' 26) Administrative Salaries (Full and pmTime)(~ s~e~No~e) l 27) Adm n strative I.'r ~ge Benelhs : '. :28) Administrative Other I 29) Other Ad/~ini I 30) Total Administrative Expenses (^dd Lines 26 through 29) 1 i'' 31) T0tal. Gx0ss Program Expenses · (^da Lines 25 and 30) ] 32) Less: Offsetting Revenue 33) Less: Anticipated Savings, if applicable 34) Net Contract Amount (Equals Line 31 less Line 32 less Line 33 ) [ : 35) If not calendar Year, indicate fiscal'year 36) Is'yoUr agency affiliated with any Other Co ~fi0ns' ~ (Yes / No) ' 37) If yes; name corporation(s), and explain y0u~ ager~¢y's affiliation. 38) Are. any program expenses paid directly by the County? (Yes / No) [ NO 39) If sO, identify expenses paid by County *Note: If an amount is entered in Line 21 (Direct Salaries) then the corresponding Top 5 individual salaries must be entered on page 4 Line 40. Additionally, if an amount is entered in Line 26 (Administrative Salaries) then the Suffolk County Contract Agency Disclosure CONTRACTOR NAME: CONTRACT: Town of Southold Supplemental Nutrition Assistance Program Reference: Page 3, questions 21 through 37 ~ Program expenses are recorded pursuant to rules and regulations promulgated by GASB and' the New York State Comptroller and are not segregated by County program. Therefore, this program specific information is not available. .... ' " I '- age4 o£' ~o~r~i~Number .. : 771 PsuedOCode::' · :" P · ,.,,t.,~'' '..... · . :. ...., Salar~ Information. · '. '.-'?::" "::."....: · · :1,,~'.. ~.',.' ': : .Sala~0unt 5~'[~gea. Public · · ': .'7 '" :'., .... '. ': ~' .:.~.',.."" . ' '. Charged.to ' ' ~o~ro~[,.. Dikcl0guri ' ' ,. · ..' .::']-T.he-resa VanEtten !42,320.47. ~Attachment., :...'.[.. Cook . ' 2 7' ·: 'Senior Ci.ti en Aide ' ',.. . . · ' ,. ~l).T0pS'Ae~nC~.Sa~es.' · . '...' : ' ' , arran ~Platley . 141 ~ 944.38 ] 0 0 . .. " p a '" 2) .[Carlisle Cochran I137,941.44 ' : .' Police Chief . . ,..::' ..... · ~} "; .."..:: '. ~ '..'~,..;: ~.:Tj' .~. - . ~' ..:. . .. · .'~....J,~rank .Kr~szeski...., ~] ~.6,811..,15 . .]. .0 ..... ~'~ 0 ~ "-'["~t s~t. ' "'::~ : "' ~' ':'~ '" .' '~'-': :' ~"~:" · ':" · ."]~olice Lt.. ' :. ~ ' · · ' ;'' ' : ' " ' ' .F6m.Prep~ed By '~itle '. Phone Number . Town Comptroller 1(631)765-4333 Agency Progrm Contact Title Phone Nmber Karen McLaughlin ~[ Dir. of Human Svcs. k631)298-4460 I ce~i~ that the data p[ov~ is ~%~ccurate to the best of my ~owledge: Psuedo Code [ . Page 2 of 4 Revenue ~N t 'N ~er t o 9 · v Transmitted Percenta e oe. tnt s9 rou_ 1 rcnresentre enuedata . ii ~ g spec fie to the program'be ng ~ported Nun ,er 20 I Irepre~elts a revenue rece red by y )t r ge icy ~ t( tat[ ;'aX~ ~, ~2_, in'om a. sourees. 9)T°talRevenueReceivedfr°mSuff°lkC°untyJ 2n 178 95 j 20 000 [] gl'o 10a) If State Aid is Received, When does the:grant expire? J 11) Federal Aid Received Directly by'Agency 11 a)If Federal Aid is Received. Whendoesthe;, grant expire? '[ 12) ~id ! Grants from Other Municipalities/Agencies[ 0 12a) Identify Other Aid Sources 16) Self:pay Revenue 17) FUnd RhiSing Revenue 18) Other Sources of Revenue 1 ga) Idefitify Other Sources of ReVenU 13) Medicare Revenue [ [ . 0 0 14) Medicaid Revenue ' ' J 0 ' J ';'. . · ,: ~¢ ..... . 0 .. , -.. 15) Third Party Insuarance ReVenue :... j j ., . 2,328..00 ,1,500.00 o 0 [] [] Cio % [] : D ©'Jo ~/° [] D~" : chi o % [] o .% 19) Total Program Revenue 20) Total Agency Revenue 23,006.95 [ 21,500.00 128,344,016.~6/ 28,102,995.25 Control Number I 7 ~/2 ' Direct Program Expenses Psuedo Code · Expenses · Page 3 of 4 2004 Actual 2005 Estimated 21) Direct Salaries (Full and PartTime) : . 22) Direct Fringe Benefits · : ' 23) Fee for Service ' :- : , . 24) Direct Other than Personnels~rvi~e§'7: 25) Total Direct Program Expense ' (A~dd i£ines'21 throt~ 24) Administrative E~pense's 26) Administrative Saiad~s (Full and Part Time)(* See Note) 27) Administrative Fringe'BenefitS 28) A~iministrativ~ Otheki~'Personnel Services 29) Other Administrative Costs 30) Total Administrative Expenses (Add Lines 26 through 29) 31) Total Gross Program Expenses (Add Lines 25 and 30) 32) Less: Offsetting Revenue 33) Less: Anticipated Savings, if applicable 34) Net Contract Amount (Equals Line 31 !ess Line 32 less Line 33) 2004 Actual 2005 Estimated" - '~. I 35) If not calendar )'car, indicate fiscal year I ymlr corperation~ 36) Is agency affiliated ~v other ? (Yes ~ 37) If yes, nanre co~,oration(s), and explain your agency's affiliation. I : 38) Are any program expenses Paid directly by the County? (Yes ~ [ 39) If So, identify expenses paid by County NO *Note: If an amount is entered in Line 21 (Direct Salaries) then the corresponding Top 5 individual salaries must be entered on page 4 Line 40; Additionally, if an amount i~ entered in Line 26 (Administrative Salaries) then the Suffolk County Contract Agency Disclosure CONTRACTOR NAME: CONTRACT: Town of Southold CSE Residential Repair Reference: Page 3, questions 21 throu:gh 37 Program expenses are recorded pursuant to rules and regulations promulgated by GASB and the New York State Comptroller and are not segregated by County program. Therefore, t~s program specific information is not available. C0fit'r0iNumber.. [ ~ 47 · ~': : 'P~ued6 Code:' I ~" ' : .... · page 4 of ..... :~ '.: ,~ .: "~ilsala~.Inforrnation:'': :'~ ':;', :.i.-:i~. ::..' ~:, i ::.~':-~..,,:,;.~:-::'-:: ~:::?'....-.'(' ..:,!..:?':;:.:,-%~Zota-'~'.i..:' --40)'T0P',5:DkeetPrO~mSala~ieS' ,-C -": : .: '' ':: 7': ',":': .... .' :..:.~ai~L,,dh~i~a '.'.:. ~ -;-.-~:.:. " .... : Sal~ ~ount ' , ,~. g . ':- ruouc: , ' .. -: -~.-.:?.:.}...: .:- '! ".- : l~. :' ;,..:' . - ." . :' 'N~; ':] 'TiffS::.; ::.:;' ;~,:;;':::~:V:., .':20'q!'T~th!~Shi~:/- ::>;.pr6~hm:: .:-.: ;. '-: . :.,..~: :::' .' '~?, ~0m?;( 'i .' %' ' ~ ' . ).tFrank Ingarra .[11,878.0.5.. } 11,878.05 ."[100 . -,-: ~' :'~ain[. ~echanic I:':.:}:':':.~ ',''. ,:,~i '}":' , -:;" '.'[.'.'A-:: :: ,:~ .:, .. :'r ;, ' : ' '- , :.: .'..:.:~: · . . .'.: ... ,..._ . . . il) .TOp 5 'Agefiey Sallies .. .: . . - ., ~ Police Captain ." '" '2) '['Carlisle Cochran '] 137,943.44 I 0 0 %' a_ ,. .' ] · . ' 5':,'..':,:"' :. : ':'. : : '~ - ,::::~'~;.':'~ ,~ ~::'.' . .~o!lce Chief -y.L' .~;..>~. ::,;r . :;," : :... · · .:'.L: '-::~. "~..~ '~!,:x,..:; '.~: .;-' ~'::~¢,i':~ ................ ; ................. i''~"'': ................ '~-':'i ............................... ':q ;~2;'::.~, "':~':}~ ;."::~::: ".':;~-." '~f? ~].~Kank. Kruszeski ~] 1 }.6,,81.1..,~ 5 .'~.., , 0 :: ,i/,.,.0 ~%:~..:..: "-,.".~ }?.~:~'5~ ~ ~ ~. ' >'~,] ~oli~ Lieutenant '. '¢']:" '~ ~' '~:'.'}}~% ~(;~{'-~'-~"~,.'~"~'" '/'.? 4).4 .... { ............... .I .... -:. .... ,~. :.~. '~ .'~ i., · !John Sinning . ~ 135 656.20 :~ 0 . -...4 ~ Q., .,~" l. Oe~. S~t. ~', " " "~ "~:'~".' .... ............. .,, .., , ..... . .... · · ~)} a i _ t133,553.09 I 0 '..~ 0, .~. ' ,"l~'~;~"'C~2'~-a~' ' I Town Comptroller 1(631)765-4333 · Agency Pr0gTam Contact Title Phone NUmber I'~aren McLaughlin [ Dir. of Human Svcs. ~63~)298-4460 I certify that the data p~oyid~ true ~d~eurate tO the best of my lmgwledge: $ignature and Date L~~..~L~yrintName/Tifle [Karen McLaughlintDir. .. Control Numbe ~ Psuedo Code ] Revenue Page 2 of 4 !ote~ Numbers 9 through 19 represent revenue data peeifi¢ to the prood~m being reported. Number 20 epresents ~11 revenue r~ceived by your agency in total om all s0i~rces: ' ' 9) Total Revenue Received eom Suffolk County 10) State Aid Received Directly by Agency 10a) If State Aid is Received, When does the grant expire? 11) Federal Aid Received Directly by Agency 11 a)lf Federal Aid is Received. When does the grant eXpire? { Aid / Grants froi:n Other Municipalities/Agencies[ 12) 12a) Identify Other Aid Sources 2004 Actual 9,789.00 Retained by 2005 Estimated Agency? 8,810.00 [] [ 0 [] Transmitted Percentage In Full toTransmitted Suffolk to Suffolk County? County? [] ~31o % 13) Medicare Revenue 14) Medicaid Revenue 15) Third Party lnSUarance Revenue 16) Self Pay Revenue 17) Fund Raising Revenue 18) Other Sources of Revenue 1 Sa) Identify Other Sources of Revenu I 0 I 0 o 0 o [] [] [] [] [] [] [] ©1o [] []lo' % [] C]]o '% I~lo % [] [] oFJ-% 19) Total Program Revenue 20) Total Agency Revenue 9,789.00 [ 8810.00 t8,344,016.~6 /28,102,995.25 32,988.00 32,988.00 32,988.00 .988.00 NO NO ~0te:~If an amount ~s entered m Line,21 (Direct Salad?s) then the corresponding ToE ~entered~. * ~': "~' on,:pa~:e_ ~4 Line. 40...'Addlti°nall. y, if.an amount: ,~'ls entered in Line. 26. (Admlmstratl~ ~ ~orrespondmg Top 5 mdtvldual salaries must be entered on page 4 Line 41. ~u: saJaries m, Suffolk County Agency Contract Disclosure CONTRACTOR NAME: CONTRACT: Town of Southold Youth Program Reference: Page 3, questions 21 through 37, Program expenses are recorded pursuant to rules and regulations promululgated by GASB and the New York State Comptroller and are not segregated by County program. Therefore, this program specific information is not available. 40) Top 5~Direct Program Salaries Psuedo Code [ Sala _ry Information % of Total Salary charged . . to Program. · Name / Title· . , . 2004 Total Salary Salary Amount Charged to . · Program Page 4 of 4 Public Disciosure Form? 2) I . I ' .~ [] / : % 41) TOP 5 Agency Salgies i) ]Martin rlatley Police Captain 2) [Carlisle Cochran ;olice Chief [ 0 % [] 137,943.44 I 0 [Police Lieutenant [.Dst. Sgtl ' 5~ , ames Ginas [Police Lt. Form Prepped By John Cushman .: 135,656~20 0 0 ': · . ' '[:~,ss3.o9 I o Title Town Comptroller I certify that the dat~ provided is t~e~and accurate to the best of my knowledge: Agency Program Contact Title [ James McMahon [ Dir. Phone Number 1(631)765-4333 PhoneNumber of Community DV~.(631)765-1283