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Home My WebLink AboutCSE - Residential RepairCONTRACT AGENCY DISCLOSURE FORM (For 2009 Budget Process) Contract A~~ 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. Please Note: In addition to completing this form, please be sure to provide Audited or Unaudited Financial Statements, IRS Form 990 or a Profit/Loss Statement for your most recent fiscal year. Suffolk County Office Use Onlv ~. Control Number 14506 Date Received . Entered By ~ Reviewed By Activity Code ~ 'Financial Statement Type: ~- Notes: r-' Department EXECUTIVE Division Office for the Aging Fund 001 Agency EXE Org 6777 Object 4980 If any of the information below has changed, you may cross out the printed information and fill in the correct information. Contract Amount: Contractor Name: Program Name: 2007 Actual : $20,400 2008 Estimate: $20,400 'own of Southold - Residential Repair Contractor Phone Number: (631) 298-4460 Extension: Contractor Contact Name: Karen McLaughlin Contractor Street Address: 53095 Main Road, P.O. Box 1179 Contractor City Address: Southold Contractor State Address: Ny Contractor Zip Code: 11971 Control Number ~- Activity Code ~ Page 2 of 4 Contract Program Revenues Part 1 -Government Grants 2007 Actual 2008 Estimated 1) Total amount of revenue received from Suffolk County for Contract Program. $ 23,874.77 $ zo' ,400.00 2) Total revenue received directly from State Government for the Contract Program. Please identify names and amounts of grant(s): 3) Total revenue received directly from Federal Government for the Contract Program. Please identify names and amounts of grant(s): 0 0 4) Total revenue received directly from all other Municipalities for the 923. oo ! o Contract Program. Please identify names and amounts of grant(s): Town of Southold _._ _ Part 2 - Medicare/Medicaid, Fundraising and All Other Revenues 5) Total revenue received from Medicare/Medicaid for the Contract Program. o U 6) Total Fund Raising revenue received for the Contract Program. ~ ~- 7) Total amount of other revenues received for the Contract Program. Please identify types of revenues and amounts below: 1160 . oo s , 300.00 Voluntary Participant Contributions -__ __ __ __ 8) Total Contract Program Revenue cnaa ~~~e5 ~ - ~~ $ z s~ 9 5 g . ~ ~ $ z s~ ~ oo . 0 0 Control Number ~ Activity Code ~ Page 3 of 4 Contract Pro rag_m Expenses Part 3 -Direct Contract Proeram Expenses 2007 Actual 2008 Estimated 9) Direct Contract Program Salaries $ 22,354.05 $ 23,136:00 10) Direct Contract Program Fringe Benefits 1, 497 , 36 1, 770. o0 11) Direct Contract Program Fee for Service 12) Direct Other Contract Program Expenses 13) Total Direct Contract Program Expenses (Add Lines 9 through 12) 0 1 0 2,108.36 2,800.00 $ 25,959.77 $ 27,706.00 Part 4 -Administrative Contract Proeram Expenses 2007 Actual 2008 Estimated 14) Administrative Contract Program Salaries 15) Administrative Contract Program Fringe Benefits 16) Administrative Contract Program Fees 17) Other Administrative Contract Program Expenses 18) Total Administrative Contract Program Expenses (Add Lines 14 through 17) 19) Total Contract Program Expenses ~- ~- (Add Lines 13 and 18) 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 -Top 5 Aeency Salaries Exceedine $100,000 Emolovee Name Emolovee Title Amouut of Salary Charged to the 2007 Salary Contract Proeram 2. 3 4.' ~I 5. ~I Control Number ~- Activity Code Agency Information Part 6 -Financial and Other Aeencv Information 2007 Actual 21) Total Agency Support and Revenues 22) Total Agency Expenses Page 4 of 4 2008 Estimated $ 31,427y687.00 $ 33,393,933.00 $ 31,843,194.00 { 36,185,333.00 23) Total Agency Net Income/(Loss) (tine n minas tine zz> X $ 415 , 507 . oo) $ 2 , 791, 400.00 24) Please indicate your fiscal yeaz if it is not the calendaz yeaz: 25a) Is your agency affiliated with any other corporations ? (Yes / No) No 25b) If yes, name corporation(s), and explain your agency's affiliation: ___ _ _. 2007 Actual 2008 Estimated 26) Total Agency Administrative Expenses '$ 5,234,683.00 $ 6,388,810.00 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) ^ Administer a corps of volunteers 1?3 Administer federal, state or other pass through funding ^ Disseminate educational materials for a public purpose ^ Administer the collection and distribution of food to the needy ^ Not Applicable for my Agency 28) I certify that enclosed herein, along with my disclosure form, is my Agency's most recent financial report (audited or unaudited Financial Statements, IRS form 990 or Profit/Loss Statement); audited Financial Statements are required, if available. I understand that if the required financial report is not enclosed my Agency will be deemed Non-Compliant until I have submitted the required report to the Comptroller's Office. SrL- Initials Form Prepazed By Title Phone Number Karen McLaughlin Town Director of Human 631 298-4460 Agency Program Contact Title services phone Number Karen McLaughlin Town Director f Human 631 298-4460 ~ServLCes If you would prefer to be contacted via E-mail, please enter an E-mail address where we may contact you in the event that we have any questions regarding the completion of this form (Optional): I certify, to the est of my knowledge and belief, that all of the information provided on this form is true and correct. Southold Town Supervisor Sign Name Title Date