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HomeMy WebLinkAboutContract Agency Disclosure Forms - HRC KAREN MCLAUGHLIN Town Director of Human Services Town of South old P.O. Box 85 750 Pacific Street Mattituck, NY 11952 Tel. (631) 298-4460 Fax (631) 298-4462 4~~ M.":'~ ~ ~~ ~" => '"""~ C) . . .... 2: ... ~ "~ . :-. . ~~O.[ '" 't-~l ~o:;rJ Nutrition Program Home Delivered Meals Case Management Essential Transportation Senior Adult Day Care/Katinka House Alzheimer's Day Care Telephone Reassurance Residential Repair July 18, 2007 Elizabeth Tesoriero, CPA Executive Director of Auditing Services Contract Compliance Unit Room S-232 Evans K. Griffmg Building 300 Center Drive Riverhead, N.Y. 11901 I Dear Ms Tesoriero, Enclosed please fmd the completed Contract Agency Disclosure Forms for the CSE Residential Repair, III C Nutrition, Transportation Assistance and Youth Programs for the Town of South old. I have not included the Town's audited financial statements for 2006 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 298-4460 or call John Cushman, Town Comptroller at 765-4333. We would be happy to assist you. cc: Elizabeth Neville, Southold Town Clerk John Cushman, Southold Town Comptroller COUNTY OF SUFFOLK (9 (....... ~n~~~ 9 2LJf 0 ~ w.. OFFICE OF THE COUNTY COMPTR N OF SOUTHOLD TING & FINANCE DEPT. JOSEPH SAWICKI, JR. Comptroller June 14, 2007 Mr. James McMahon Town of South old Town Hall - Main Road Southold, NY 11971 Dear Mr. McMahon: 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. 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 of your contracts with Suffolk County. If you have any questions regarding completion of the form, please call either 631-852-2064 or 631-852-2062. Please complete and return the disclosure form(s), as well as a copy of your agency's audited 2006 financial statements to the following address, no later than July 3 I, 2007. Suffolk County Comptroller's Office Contract Compliance Unit - Room 5-232 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 2008 operating budget. Thank you for your anticipated cooperation. Very truly yours, (!~..r~ Elizabeth Tesoriero, CPA Executive Director of Auditing Services CONTRACT COMPLIANCE UNIT - ROOM 8.232 . EV AN8 K. GRIFFING BUILDING. 300 CENTER DRIVE. RIVERHEAD, NY 11901 Phone (631) 852-2064 Fax (631) 852.2066 COUNTY OF SUFFOLK (iI OFFICE OF THE COUNTY COMPTROLLER JOSEPH SAWICKI, JR. Comptroller June 14, 2007 Ms. Karen McLaughlin, Director Town of South old 53095 Main Rd, P.O. Box 1179 Southold, NY 11971 Dear Ms. McLaughlin: 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. 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 of your contracts with Suffolk County. If you have any questions regarding completion of the form, please call either 631-852-2064 or 631-852-2062. Please complete and return the disclosure form(s), as well as a copy of your agency's audited 2006 financial statements to the following address, no later than July 31, 2007. Suffolk County Comptroller's Office 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 2008 operating budget. Thank you for your anticipated cooperation. Very truly yours, ~~.:r~ Elizabeth Tesoriero, CPA Executive Director of Auditing Services CONTRACT COMPLIANCE UNIT - ROOM 5-232 . EVANS K. GRIFFING BUILDING. 300 CENTER nRlvE. RIVERHEAD, NY 11901 Phone (631) 852-2064 Fax (631) 852-2066 <. Instructions for Completine: Contract Ae:encv Form "Contract Al!encv Information" - (Form Pal!e 1 of 4) Each form consists of four pages and has a control number on top of each page. Pal!e 1. "Contract Al!encv Information." contains information related to the contracted prOl!ram for which Information is belnl! requested. Please review this information, fill in any blanks and correct any inaccurate information directly on the form. Please Note: Each Contract Agency Disclosure Form is specific to the information listed on page I; therefore, if you have more than one contracted program, you will need to fill out another Contract Agency Disclosure Form for each program. Do not combine multiple prOl!rams onto one form. Please only list amounts relevant to your contracted program. If you fail to list only amounts that are specific to the contracted program, this form will be deemed incomplete and your agency will be in non-compliance. Information is being requested for the 2006 and 2007 calendar years. If your financial records are not maintained on a calendar year basis, please report on the two fiscal years ending in 2006 and 2007. Also, indicate on page 3, line 32 the fiscal year being reported on. Please Note: If you fail to properly complete this disclosure form your agency will be deemed non-compliant and funding for your program(s) may be eliminated for future years. "Revenues" - (Form Pal!e 2 of 4) When preparing the Revenue section, the 2006 revenues should be based on actual revenues earned in accordance with generally accepted accounting principles or reported based on the terms of your contract, if different. The 2007 data should be based on budgeted amounts for the entire year. Please onlv list revenues that were used to fund the contracted prol!ram. 9) "Revenue Received from Suffolk County for Contracted Prol!fam" - Enter the total amount of revenue received/anticipated to be received for your program as a result of your agency's contract with Suffolk County. These amounts are listed on Page I of this form. 10) "State Aid Received For Contracted Prol!ram" - Enter the amount of state aid received/anticipated to be received directly by your agency that only supports the contracted program. II) "Federal Aid Received For Contracted Prol!ram" - Enter the amount of federal aid received/anticipated to be received directly by your agency that only supports the contracted program. 12) "Aid/Grants from Other Municipalities! Al!encies for Contracted Prol!ram" - Enter the amount of any aid or grant revenue received/anticipated to be received from any other municipalities or agencies (Villages, Towns, Corporate, etc.) that only supports the contracted program. 12a) "Identify Other Aid/Grants- If an amount was entered on line 12, please identify all source(s) and related amount(s). 13) "Medicare Revenue" - Enter the amount of any Medicare revenue received that only supports the contracted program. 14) "Medicaid Revenue" - Enter the amount of any Medicaid revenue received that only supports the contracted program. 15) "Third-Party Insurance Revenue" - Enter the amount of any third-party insurance revenue received that only supports the contracted program. 16) "Fund Raising Revenue" - Enter the amount of any fund raising revenue received by your agency that only supports the contracted program. (e.g., Sponsorships, etc.) 17) "Other Sources of Revenue" - Enter the amount of any other source of revenue not included on lines 9 through 16 that also supports the contracted program. (e.g., registration, membership fees, etc.) 17a) "IdentifY Other Sources of Revenue" - If an amount has been entered on line 17, list the source(s) of the other revenue and related amount(s). 18) "Total Program Revenue" - Indicate the total program revenue for 2006 and estimated program revenue for 2007 that is related soIelv to the contracted program. (This should equal the sum oflines 9 through 17) 19) "Total Agencv Revenue" - Indicate the total agency revenue for 2006 and estimated agency revenue for 2007 that is related to the al!enev as a whole. This number can typically be found on your agency's audited financial statements on the "Statement of Activities" as Total Support and Revenue. If your agency does not have audited financial statements, this amount may be found on an income statement, profit/loss statement or on line 12 on IRS Form 990. "Expenses" - (Form Pal!e 3 of 4) When preparing the Expense section, the 2006 actual amounts should be based on expenses claimed and approved based on the terms of your contract. The 2007 data should be based on budgeted amounts for the entire year. If you have questions regarding whether or not expenses are either "Direct" or "Administrative" please call the Contract Compliance Unit at the number listed on the letter you received along with this Disclosure Form. Please list only expenses that pertain to the contracted program. Direct Prol!ram Expenses 20) "Direct Salaries" (Full and Part-Time) - Enter the total amount of all direct salaries paid to all full and part-time workers whose salaries are charged in full or in part to the contracted program. Salary amounts entered should be the salary amount actually charged to the contracted program. Direct Salaries are those paid to those who work directly with the contract program, typically individuals who are considered to work "In the field". (e.g. Counselor, Nurse, Teacher, Etc) If an amount is listed on this line. vou are required to list the Top 5 individuals on line 37 "Too 5 Direct Prol!ram Salaries" on Pal!e 4 oflhis form. 21) "Direct Fringe Benefits" - Enter the amount charged to the program for all fringe benefits related to the full and part-time direct personnel charged to the contract program. Fringe benefit amounts should include employer portion of payroll taxes, health and dental benefits, pension benefits, and any other benefits or perks provided to employees of your agency that are paid for through the contracted program. Page 2 of 4 22) "Fee for Service" - Enter the amount of expense for services that are paid for by your agency, but provided by businesses or individuals outside of your agency (e.g., housekeeping, lab services, phone services, contract labor, maintenance, etc.). 23) "Direct Other than Personnel Service" - Enter the amount of all other direct expenses related to the contracted program being reported on that were not reported on lines 21, 22, and 23 (e.g., sport or other equipment, supplies used by direct salaried workers, travel expenses, uniforms, etc.). 24) "Total Direct Prol!fam Expense" - Add lines 20 through 23 Administrative Expenses 25) "Administrative Salaries" (Ful1 and Part-Time) - Enter the amount of all administrative salaries paid to all ful1 and part-time workers whose salaries are charged in ful1 or in part to the contracted program. Salary amounts entered should be the salary amount actual1y charged to the contracted program. Administrative Salaries are those paid to those who didn't necessarily work with the contracted program. (e.g., CEO, CFO, Bookkeeper, File Clerk) If an amount is listed on this line. vou are required to list the Top 5 individuals on line 38 "Top 5 Administrative Proeram Salaries" on Paee 4 of this form. 26) "Administrative Frinee Benefits" - Enter the amount of all fringe benefits related to all ful1 and part-time administrative personnel charged to the contracted program. Fringe benefit amounts should include employer portion of payrol1 taxes, health and dental benefits, pension benefits, and any other benefits or perks provided to employees of your agency that are paid for through the contracted program. 27) "Administrative Fees" - Enter the amount of all legal fees, accounting fees, consulting fees, and other type of professional fees that are related to administrative purposes. 28) "Administrative Other than Personnel Service" - Enter the amount of all other expenses related to the administration of the contracted program being reported on (e.g., rent, office equipment & supplies, insurance, etc.). 29) "Total Administrative Expenses" - Add lines 25 through 28 30) "Total Gross Proeram Expenses" - Add line 24 and line 29. 31) "Total Aeencv Expenses" - Indicate the total agency expenses for 2006 and estimated total agency expenses amount for 2007 that are related to the agency as a whole. This number can typical1y be found on your agencies audited financial statements on the "Statement of Activities" as Total Expenses. If your agency does not have audited financial statements, this amount may be found on an income statement, profit/loss statement or on line 17 of IRS Form 990. 32) "If not calendar year. indicate fiscal year" - If the information provided is not based on a calendar fiscal year, please indicate the fiscal period used for reporting. 33) "Is your aeency affiliated with any other corporations? (YesINo)" - Please indicate whether your agency has either a direct or indirect affiliation with any other corporation(s) or agency(s). Page 3 of 4 " 34) "If Yes. name corooration(s). and exolain your agency's affiliation." - If line 33 is "Yes," indicate which corporation(s) or agency(s) your agency is affiliated with, and what type of affiliation your agency has with that corporation(s) or agency(s). 35) "Are any orogram exoenses oaid directlv bv the County? (Yes/No )" - Indicate whether any program-related expenses are paid on behalf of the program or agency directly by Suffolk County. 36) "If so. identify exoenses wid bv the County" - If any expenses are paid directly by the County, indicate the type of expense and the amount paid, if known. Salary Information - (Form Pal!e 4 of 4) 37) "Too 5 Direct Program Salaries" - List the top five employees who perform direct duties for the program. For each individual listed, provide name, title/position, 2006 annual salary listed on the W-2 or 1099, the amount of the 2006 salary that was charged to the contracted program, and the percent of that salary charged to the program. Please Note: Ifthere is an amount on page 3, line 20 "Direct Salaries" you must fill this information out. If this Information Is left blank and there is an amount listed on line 20 of this disclosure form. it wUl be deemed incomolete and your aeencv wUl be in non-comoliance. 38) "Too 5 Agencv Salaries" - Based on 2006 total salaries, list the top five employees who perform administrative duties for the program. For each individual listed, provide name, title/position, 2006 annual salary listed on the W-2 or 1099, the amount of the 2006 salary that was charged to the contracted program, and the percent of that salary charged to the contracted program. Please Note: If there is an amount on page 3, line 25 "Administrative Salaries" you must fill this information out. If this information is left blank and there is an amount listed on line 26 of this disclosure form. it wID be deemed incomolete and your aeency wili be in non-comoliance. "Form Preoared Bv" - Please provide this information as requested so that we may contact the appropriate person should we have questions regarding the completion of the form or the information provided. "Aeency Program Contact" - Please provide the information as requested. This person should be the person most likely to be able to answer questions regarding the financial information related directly to the program being reported on. Page 4 of 4 . CONTRACT AGENCY DISCLOSURE FORM (For 2008 Budget Process) Contract Agency Information Page 1 of4 Before completing this form, please read the instructions in order to ensure that accurate, relevant and consistent information is provided. Uyou have any questions regarding completion of this form please refer to the contact information in the attached letter. Note: In addition to completing this form, please be sure to provide audited financial statements for the 2006 fiscal period. Suffolk County Office Use Only Entered By r Reviewed By r Date Received Financial Statement Type: I Notes 1 1) Department IEXECUTIVE 2) Division IOffice for the Aging Control Number 113375 3) Fund 1001 Agency IEXE Object 14980 4) Pseudo Code 5) Contractor Name 5a) Program Name 6) Contractor Phone Number 6a) Phone Extension 7) Contractor Contact 8) Contractor Street Address Contractor City Address Contractor State Address Contractor Zip Code Org 16806 Contract Amount I 2006 Actual $4,600 2007 Estimate $9,217 ITown of Southo1d ITransportation Assistance Program Ie 631) 298-4460 I IKaren McLaughlin 153095 MainRd, P.O. Box 1179 ISoutho1d INY 111971 Control Number Psuedo Code I Page 2 of 4 Revenues Note: Nwnbers 9 through 18 represent revenue data specific to the program being reported. Number 19 represents all revenue received by your agency in total from all sources. 2006 Actual 2007 Estimated Contracted Program Revenue 9) Revenue Received from Suffolk County for Contracted Program $4,600.00 $10,656.00 10) State Aid Received for Contracted Program 11) Federal Aid Received for Contracted Program 12) Aid/Grants from Other Municipalities/Agencies For Contracted Program 13) Medicare Revenue I N/A I N/A 14) Medicaid Revenue I I N/A N/A 15) Third Party Insurance Revenue I I N/A N/A 16) Fund Raising Revenue I N/A I N/A 17) Other Sources of Revenue I I 17a) IdentifY Other Sources of Revenue I I 18) Total Program Revenue (Add Lines 9 - 17) 1$4,600.00 $10,656.00 19) Total Agency Revenue 1$30,285,709.00 $30,291,787.00 Control Number Psuedo Code Page 3 of 4 wenses Direct Program Expenses 20) Direct Salaries (Full and Part Time)(* See Note) 2006 Actual 2007 Estimated $9,145.21 I I $ I I $ I 456.00 $10,656.00 21) Direct Fringe Benefits 22) Fee for Service $ 699.61 23) Direct Other than Personnel Services 700.00 (Add Lines 20 through 23) Administrative Expenses 25) Administrative Salaries (Full and Part Time1* See Note) I 26) Administrative Fringe Benefits I 27) Administrative Fees I 28)Administrative Other than Personal Services I 29) Total Administrative Expenses (Add Lines 25 through 28) I $9,844.82 2006 Actual $11,812.00 2007 Estimated I I I I I 30) Total Gross Program Expenses (Add Lines 24 and 29) I $9,844.82 $11,812.00 b30,566,565.851$33,817,133~0 I 31) Total Agency Expenses 32) If not calendar year, indicate fiscal year 33) Is your agency affiliated with any other corporations ? (Yes / No) 34) rfyes, name corporation(s), and explain your agency's affiliation. NO 35) Are any program expenses paid directly by the County? (Yes / No) 36) If so, identify expenses paid by County NO *Note: If an amount Is entered In Line 20 (Direet Salaries) then the corresponding Top 5 individual salaries must he entered on page 4 Line 37. AddltionaUy, if an amount Is entered in Line 25 (Administrative Salaries) then the corresponding Top 5 Individual salaries must he entered on page 4 Line 37. Control Number Psuedo Code I Salary Information Page 4 of 4 $9,145.21 Amount of Salary Charged to Program I Please See % of Total Salary Charged to Program 37) Top 5 Direct Program Salaries Name / Title I) I Thomas Nielson I Mini Bus Driver 2006 Total Salary Attached % 2) I I 3) I I 4) I I r 5) I J I % % % % 38) Top 5 Agency Salaries 1$88,583.50 1) I Karen McLaughlin . IDir. of Human Services 2) I Tprry.V<=lIn'Rrt-c.n I Senior Center Manager 3) I JanE'! F.<i",trnm Isenior Clerk Typist 4) I ~hp.:ryl . K;:U:::WIO 11 I Account Clerk Typist 5)/ I I $53,007.64 $47,499.15 1$42,983.73 r Form Prepared By I :Karen McLaughlin Agency Program Contact IKaren McLaughlin I certify that the data Signature and Date Title Phone Number IDir. of Human servic4s 631-298-4460 Title Phone Number IDir. of Human servic4s 631-196 -4460 e best of my knowledge: I If(! r: . Suffolk County Contract Agency Disclosure CONTRACTOR NAME: Town of South old CONTRACT: Transportation Assistance Program Reference: Page 3, questions 20 through 32 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's specific financial information is not determinable. July 16, 2007 CONTRACT AGENCY DISCLOSURE FORM (For 2008 Budget Process) Contract Agency Information Page 1 of4 Before completing this form, please read the instructions in order to ensure that accurate, relevant and consistent information is provided. If you have any questions regarding completion ofthis form please refer to the contact information in the attached letter. Note: In addition to completing this form, please be sure to provide audited financial statements for the 2006 fiscal period. Suffolk County Office Use Only Entered By r Reviewed By r- Date Received Financial Statement Type: I Notes 1 1) Department ImmCUTIVE 2) Division IOffice for the Aging Control Nwnber 112353 Object 14980 Agency lE)m Org 16790 3) Fund 1001 4) Pseudo Code 5) Contractor Name 5a) Program Name 6) Contractor Phone Nwnber 6a) Phone Extension 7) Contractor Contact 8) Contractor Street Address Contractor City Address Contractor State Address Contractor Zip Code Contract Amount I 2006 Actual $214,312 2007 Estimate $179,403 ITown of Southold Imc Nutrition 1(631) 298-4460 IKaren McLaughlin, Director 153095 Main Road, P.O. Box 1179 ISOUth01d INY 111971 Control Number Psuedo Code Page 2 of4 Revenues Note: Numbers 9 through 18 represent revenue data specific to the program being reported. Number 19 represents all revenue received by your agency in total from all sources. 2006 Actual 2007 Estimated Contracted Program Revenue 9) Revenue Received from Suffolk County for Contracted Program $200,013.16 $226,528.00 I II) Federal Aid Received for Contracted Program I I I I I 10) State Aid Received for Contracted Program 12) Aid/Grants from Other Municipalities/Agencies For Contracted Program 13) Medicare Revenue I N/A I N/A 14) Medicaid Revenue I I 15) Third Party Insurance Revenue I ~l.'~ I N!7\ N/A N/A 16) Fund Raising Revenue I N/A I N/A 17) Other Sources of Revenue I I 17a) Identify Other Sources of Revenue Voluntary Contribution~ $111,657.03 $110,500 18) Total Program Revenue (Add Lines 9 - 17) 1$311,670.19 1$30,285,709.00 $337,028.00 19) Total Agency Revenue $30,291,787.00 Control Number Psuedo Code Page 3 of4 wenses Direct Program Expenses 20) Direct Salaries (Full and Part Time)(* See Note) 21) Direct Fringe Benefits " 2007 Estimated i",Ch.. " 2006 Actual Please See 22) Fee for Service " " 23) Direct Other than Personnel Services " " (Add Lines 20 through 23) Administrative Expenses 2006 Actual 2007 Estimated 25) Administrative Salaries (Full and Part Time~* See Note) I please see ~ttached 26) Administrative Fringe Benefits I " r " 27) Administrative Fees I " I " 28)Administrative Other than Personal Services I " I " 29) Total Administrative Expenses (Add Lines 25 through 28) I " I " 30) Total Gross Program Expenses (Add Lines 24 and 29) I I " " 31) Total Agency Expenses I I " " 32) Ifnot calendar year, indicate fiscal year I 33) Is your agency affiliated with any other corporations? (Yes I No) I NO 34) If yes, name corporation(s), and explain your agency's affiliation. 35) Are any program expenses paid directly by the County? (Yes I No) 36) If so, identify expenses paid by County NO "Note: If an amount Is entered In Line 20 (Dlreet Salaries) then the corresponding Top S Individual salaries must be entered on page 4 Line 37. Additionally, If an amount Is entered In Line 2S (Administrative Salaries) then the corresponding Top S Individual salaries must be entered on page 4 Line 37. Control Number 37) Top 5 Direct Program Salaries Name / Title I)~ike DeVito.. ~enior . Cook 2) IPhyllis Markopolous Icaseworker Trainee 3) IMarvin Knight IMini Bus Driver 4) lAngeI Morales I Food Service worker 5) L A~anda Fink I Assistant Cook 38) Top 5 Agency Salaries I) I Karen MC~aUghlin I Dir. of Human Services 2) I Terry Van Etten I Senior Center Manager 3) ~e Edstrom. 1 Senior Clerk Typist ~ rC~erYI Kaswell I~ccount Clerk Typist 5) 1 1 Psuedo Code I Salary Information Page 40f4 2006 Total Salary 1$38,145.35 Amount of Salary Charged to Program Iplease See % of Total Salary Charged to Program r-% Attached 1$32,142.63 I II II % I II 1$30,321.39 % II 1$$28,728.96 I II II % I 1$25,072.65 I · % II I II 1~88: 583.50 II % I 1$53,007.64 .1 II % II I II 1$47,499.15 II % I II 1$42,983.73 II % I % Form Prepared By jKaren McLaughlin Agency Program Contact I Karen McLaughlin . ed is Signature and Date Title Phone Number IDir. of Human servic,s 631-298-4460. Title Phone Number IDir. of Human servic+s 631-298-4460 the best of my knowledge: I /<'~G7\I M<:..LAt< It I,^- 'T~~ t~. Suffolk County Contract Agency Disclosure CONTRACTOR NAME: Town of Southold CONTRACT: IIIC Nutrition Reference: Page 3, questions 20 through 32 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's specific financial information is not determinable. July 16, 2007 , CONTRACT AGENCY DISCLOSURE FORM (For 2008 Budget Process) Contract Agency Information Page 1 of4 Before completing this form, please read the instructions in order to ensure that accurate, relevant and consistent information is provided. If you have any questions regarding completion of this form please refer to the contact information in the attached letter. Note: In addition to completing this form, please be sure to provide audited financial statements for the 2006 fiscal period. Suffolk County Office Use Only Entered By C Reviewed By I Date Received Financial Statement Type: I Notes I 1) Department IEXECUTIVE 2) Division IOffice for the Aging Control Number 113083 3) Fund 1001 Org 16777 Agency IEXE Object 14980 4) Pseudo Code IN/A 5) Contractor Name 5a) Program Name 6) Contractor Phone Number 6a) Phone Extension 7) Contractor Contact 8) Contractor Street Address Contractor City Address Contractor State Address Contractor Zip Code Contract Amount 1 2006 Actual $20,400 2007 Estimate $20,400 ITown of Southold ICSE - Residential Repair 1(631) 298-4460 IKaren McLaughlin, Director 153095 Main Road, P.O. Box 1179 ISouthold INY 111971 Control Number Psuedo Code Page 2 of 4 Revenues Note: Numbers 9 through 18 represent revenue data specific to the program being reported. Number 19 represents all revenue received by your agency in total from all sources. 2006 Actual 2007 Estimated Contracted Program Revenue 9) Revenue Received from Suffolk County for Contracted Program $20,167.96 $20,400.00 I I I 10) State Aid Received for Contracted Program II) Federal Aid Received for Contracted Program 12) Aid/Grants from Other Municipalities/Agencies For Contracted Program 13) Medicare Revenue I 14) Medicaid Revenue NIl'. I Nl~ 15) Third Party Insurance Revenue I 16) Fund Raising Revenue I 17) Other Sources of Revenue I 17a) IdentifY Other Sources of Revenue Voluntary Contributions $2,201 $3,000 18) Total Program Revenue (Add Uno. 9 - 17) 1$22,368.96 I $30,285,709 $23,400.00 19) Total Agency Revenue $30,291,787 Control Number /13083 Psuedo Code Expenses Direct Program Expenses 20) Direct Salaries (Full and Part Time)<* See Note) 21) Direct Fringe Benefits 22) Fee for Service 23) Direct Other than Personnel Services (Add Lines 20 through 23) Administrative Expenses 25) Administrative Salaries (Full and Part Timer See Note) 26) Administrative Fringe Benefits 27) Administrative Fees 28)Administrative Other than Personal Services 29) Total Administrative Expenses (Add Lines 25 through 28) 30) Total Gross Program Expenses (Add Lines 24 and 29) 2006 Actual 1$22,198.84 1$1,698.21 I o I P HA Q1 . 1 $26,361.96 Page 3 of 4 2007 Estimated $26,978.00 $2,050.00 o ~.,.t:nn nn $31,448.00 2006 Actual 2007 Estimated 1$26,361.96 31) Total Agency Expenses 1 32) If not calendar year, indicate fiscal year I 33) Is your agency affiliated with any other corporations ? (Yes / No) 34) If yes, name corporation(s), and explain your agency's affiliation. I I I I I 1$31,448.00 NO 35) Are any program expenses paid directly by the County? (Yes / No) 36) If so, identifY expenses paid by County NO *Note: If an amount Is entered in Line 20 (Direct Salaries) then the corresponding Top 5 individual salaries must be entered on page 4 Line 37. Additionally, if an amount is entered In Line 25 (Administrative Salaries) then the corresponding Top 5 Individual salaries must be entered on page 4 Line 37. % of Total Amount of Salary Salary Charged Charged to to Program 2006 Total Salary Program I % $13,904.74 $13,904.74 100 I I 1100 % $8,294.10 $8,294.10 ~ Control Number 113083 Psuedo Code Salary Information 37) Top 5 Direct Program Salaries Name / Title 1)1 Frank Ingarra I Maint. Mechanic I 2) I I 3) I I 4) I I 5) I , Joe Magagnin I 38) Top 5 Agency Salaries 1) I Karen McLauqhlin . IDir. of Human Services 2) Ir.hri "f-inp n,..,..,,,l<,..,,,ld I Clerk'l'ypi"f- 3) I IOBeF}'"l na.3ncll ~ccount Clerk Tvoist 4) I I 5>1 I I $88,583.50 I o I $43,339.05 o I I $42,983.73 o Form Prepared By IKar.en ' McLaughlin Agency Program Contact IKaren Title IDir. Title Phone Number Page 4 of 4 % I % r % 1 % 0 % 0 % 0 % % of Human servicls 631-298-4460 Phone Number IDir. of Human servicJs 631-298-4460 o the best of my knowledge: I !'III2EN /l1cJ.4u.aliLtA.! J . <:) . "fa uJ IV tJ P Sour!fOLi::, Signature and Date . Suffolk County Contract Agency Disclosure CONTRACTOR NAME: Town of Southold CONTRACT: CSE Residential Repair Reference: Page 3, questions 20 through 32 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's specific financial information is not determinable. July 16, 2007 CONTRACT AGENCY DISCLOSURE FORM (For 2008 Budget Process) Contract Agency Information Page 1 of4 Before completing this form, please read the instructions in order to ensure that accurate, relevant and consistent information is provided. !fyou have any questions regarding completion of this form please refer to the contact information in the attached letter. Note: In addition to completing this form, please be sure to provide audited financial statements for the 2006 fiscal period. Suffolk County Office Use Only Entered By r Reviewed By r Date Received I Financial Statement Type:1 Notes I I) Department IHUMANSERVICES 2) Division IY()UTHI3lJ~AU Control Number 112602 3) Fund 1001 Agency IEXE Org /7320 Object 14980 2006 Actual 2007 Estimate $10,185 ;1 $10,316 4) Pseudo Code I~l .... Contract Amount I ITown ofSouiliold 'YOUili Program 5) Contractor Name 5a) Program Name 6) Contractor Phone Number 1(631) 765~ 1283 6a) Phone Extension 7) Contractor Contact 1 Contractor City Address IJames McMahon ITown Hall - Main Road ISouiliold 8) Contractor Street Address Contractor State Address Contractor Zip Code INY 111971 Control Number Psuedo Code I ARHl 112602 Note: Numbers 9 through 18 represent revenue data specific to the program being reported. Number 19 represents all revenue received by your agency in total from all sources. Contracted PrOgram Revenue 9) Revenue Received from Suffolk County for Contracted Program 10) State Aid Received for Contracted Program 11) Federal Aid Received for Contracted Program 12) Aid/Grants from Other Municipalities/Agencies For Contracted Program 13) Medicare Revenue 14) Medicaid Revenue 15) Third Party Insurance Revenue 16) Fund Raising Revenue 17) Oilier Sources of Revenue 17a) IdentifY Oilier Sources of Revenue [ I 18) Total Program Revenue (AddLines9-17) 19) Total Agency Revenue Revenues 2006 Actual 10,185 I I I I I 10,185 130,285,709 Page 2 of 4 2007 Estimated 10,316" 1 I I I I 10,316 bO,291,787 Control Number 112602 Psuedo Code I ARH1 Page 3 of 4 Expenses Direct Program Expenses 20) Direct Salaries (Full and Part Time)(" See Note) 2006 Actual 2007 Estimated (Add Lines 20 through 23) I I I I I 21) Direct Fringe Benefits 22) Fee for Service 23) Direct Other than Personnel Services 32,988 32,988 32,988 '32,988 Administrative Expenses 25) Administrative Salaries (Full and Part Timet" See Note) I 26) Administrative Fringe Benefits I 27) Administrative Fees I 28)Administrative Other than Personal Services I 29) Total Administrative Expenses (Add Lines 2S through 28) I 30) Total Gross Program Expenses (Add Lines 24 and 29) I 2006 Actual 2007 Estimated 32,988 I I 32,988 31) Total Agency Expenses 63,817,133.00 32) If not calendar year, indicate fiscal year 33) Is your agency affiliated with any other corporations ? (Yes / No) 34) If yes, name corporation(s), and explain your agency's affiliation. 130,566,565.85 I 35) Are any program expenses paid directly by the County? (Yes /No) 36) If so, identify expenses paid by County .Note: IT an amonnt Is entered In Line 20 (DIrect Salaries) then the corresponding Top 51ndlvldual salaries must be entered on page 4 Line 37. Additionally, If an amount Is entered In Line 25 (Administrative Salaries) then the corresponding Top 51ndlvldual salaries mnst be entered on page 4 Line 37.