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Home My WebLink AboutContract Agency Disclosure FormsKAREN McLAUCHLIN Town Director of Human Services Town of Southold 750 Pacific Street P.O. Box 85 Mattituck, NY 11952 Tel. (631) 298-4460 Fax (631)298-4462 Dear Betty, ~~SOFFO(,~C~ ~~o oy~, N 2 O ~ ~, y~ol ~ ~a~~ Nutrition Program Home Delivered Meals Case Management Essential Transportation Senior Adult Day Care Alzheimer's Day Care Telephone Reassurance Residential Repair Attached please find 3 Contract Agency Disclosure Forms that I completed for the Human Resource Center. I reviewed them with John Cushman and they are ready for the Supervisor's initials and signature. (I marked each of the forms where Scott's initials or signature are required.) Once they are signed, I would ask that you retain a copy in your office and return the originals to me as I will forward them with a cover letter to Elizabeth Tesoriero at the County Comptrollers Office. Thank you for your assistance. It is very much appreciated. Karen COUNTY OF SUFFOLK OFFICE OF THE COUNTY COMPTROLLER JOSEPH SAWICKI, JR. Comptroller June 13,2008 Ms. Karen McLaughlin Town of Southold 53095 Main Road, 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), along with a copy of your agency's most recent audited financial statements to the following address, no later than July 31, 2008. 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 2009 operating budget. Thank you for your anticipated cooperation. Very truly yours, Elizabeth Tesoriero, CPA Executive Director of Auditing Services CONTRACT COMPLIANCE UNIT- ROOM 5-232 • EVANS K. GRIPPING BUILDING •300 CENTER DRIVE • RIVERHEAD, NY 11901 (631) 852-2064 Fax (63q 852-2066 CONTRACT AGENCY DISCLOSURE FORM (For 2009 Budget Process) Contract Agency Information Page 1 of 4 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 Countv Office Use Onlv Control Number 13795 Entered By ~ Reviewed By ~ Date Received ~I r i Activity Code I ~ ;Financial Statement Type: ~- Notes: ~~~ Department Division Fund --. _- __ _ EXECUTIVE Office for the Aging 001 Agency EXE Org 6806 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: 2007 Actual : ~- $11,357 2008 Estimate: ~ $11,357 Contractor Name: Town of Southold Program Name: Transportation Assistance Program 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 ~- Contract Program Revenues Part 1 -Government Grants 1) Total amount of revenue received from Suffolk County for Contract Program. 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): __ _ __ _ .. 4) Total revenue received directly from all other Municipalities for the Contract Program. Please identify names and amounts of grant(s): Town of Southold o i o $ 51.88 I 0 Part 2 - Medicare/Medicaid, Fundraisine and All Other Revenues 5) Total revenue received from Medicare/Medicaid for the Contract ~~ ~1 ~ Program. 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: Page 2 of 4 2007 Actual 2008 Estimated $9,315.81 $ 11,357.CG I O I Q $ 2,235.00 $ 4,500:00 8) Total Contract Program Revenue (naa u~e5 i • ~~ $ 11, 602.69 $ 15 , 857.00 Control~Number ~ Activity Code ~ Page 3 of 4 Contract Pro ragL m Expenses Part 3 -Direct Contract Pro¢ram Expenses 2007 Actual 2008 Estimated 9) Direct Contract Program Salaries 10) Direct Contract Program Fringe Benefits 11) Direct Contract Program Fee for Service 12) Direct Other Contract Program Expenses $ 6,680.81 $ 10,497.00 511.88 803.00 0 ~0~0 $ 4,400.00 I 4,557.00 13)TotalDirectContractProgramExpenses $ 11,602.69 $ ls,s57.oo (Add Lines 9 through 12) Part 4 -Administrative Contract Pro¢ram 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 l7) 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 Aeencv Salaries Exceedine $100,000 Amount of Salary Charged to the Emolovee Name Employee Title 2007 Salary Contract Program 1. 2. ~ ~~ 3. ~~ 4. ~~ 5. ~ !~ Control Number l u Activity Code ~- Agency Information Part 6 -Financial and Other At=.encv Information 21) Total Agency Support and Revenues 22) Total Agency Expenses 23) Total Agency Net Income/(Loss) (Line 21 minus Line 22) 24) Please indicate your fiscal yeaz if it is not the calendar year: 2007 Actual Page 4 of 4 2008 Estimated $31,427,687.00 $ 33,393,933.00 31,843,194.00 36,185,333.00 ( $ 415,507.00) $ 2,791,400.00 25a) Is your agency affiliated with any other corporations ? (Yes / No) ZSb) If yes, name corporation(s), and explain your agency's affiliation: 26) Total Agency Administrative Expenses 2497 Actual No 2Qt18 Estimated 27) Does your Agency: (Check all that apply, if none apply please check the box mnrked not applicable) _! Administer a corps of volunteers 'x'~ Administer federal, state or other pass through funding Disseminate educational materials for a public purpose J Administer the collection and distribution of food to the needy n 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. 5~ Initials .. Forrrt Prepared By Title Phone Number Karen McLaughlin Towl n Director of Human Serv ce~ 298-4460 Agency Program Contact Title Phone Number Karen McLaughlin Town Director of Human Serv ces 631 298-4460 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 regazding the completion of this form (optional): I certify, to e best of my lmowledge and belief, that all of the information provided on this form is true and correct. ~• - C/rV sign xame rue Southold Town Supervisor care .• CONTRACT AGENCY DISCLOSURE FORM (For 2009 Budget Process) Contract Agency Information Page 1 of 4 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 { ~ Entered By ~ Reviewed By ~ Date Received ~~~ Activity Code ~` Financial Statement T e: i YP ~~~ Notes: _- - __ _- __ _ __ 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: 2007 Actual : ~ $20,400 2008 Estimate: ~ $20,400 Contractor Name: Program Name: oI Southold - Kesfdenhal Kepair Contractor Phone Number: (631) 298-4460 ~ Extension: ~~ Contractor Contact Name Contractor Street Address: Contractor City Address Contractor State Address: Contractor Zip Code: Karen McLaughlin 53095 Main Road, P.O. Box 1179 Southold NY 11971 Control Number r- Activity Code ~ Page 2 of 4 / Contract Program Revenues Part 1 -Government Grants 2007 Actuat 2008 Estimated 1) Total amount of revenue received from Suffolk County for Contract Program. S 23,874.77 ' $' 20 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): 4) Total revenue received directly from all other Municipalities for the Contract Program. Please identify names and amounts of grant(s): Town of Southold __ _ _._. o o 0 0 925.00 Part 2 -Medicare/Medicaid, Fundraising and All Other Revenues 5) Total revenue received from Medicaze/Medicaid for the Contract Program. 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: Voluntary Participant Contributions __-- __ _. 8) Total Contract Program Revenue (Add Lines I - 7) 1 0 'I o 1 O I O 11# 60.00 51 300.00 $ 25,J 959.77 $ 25 Control Number ! Activity Code ~ Page 3 of 4 Contract Pro ram Expenses Part 3 -Direct Contract Program 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 1,770.00 11) Direct Contract Program Fee for Service 12) Direct Other Contract Program Expenses 13) Total Direct Contract Program Expenses (Add Lines 9 through 12) o 0 2,108.36 2,800.00 $ 25,959.77 $ 27,706.00 Part 4 -Administrative Contract Program 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 I S) 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 -Top 5 Agencv Salaries Exceeding $100,000 Amount of Salary Charged to the Emolovee Name Emolovee Title 2007 Salary Contract Program ]. 2. 3. r ~_ 4. ~~ 5 f Control Number '~- Activity Code ~- A ency Information Part 6 -Financial and Other A¢encv Information 2007 Actual 21) Total Agency Support and Revenues 22) Total Agency Expenses 23) Total Agency Net Income/(Loss) (tine zt minas tine zz) Page 4 of 4 2008 Estimated $ 31,427~~687.00 $ 33,393,933.00 '$ 31,843,194.00 36,185,333.00 $415,507.00) 24) Please indicate your fiscal yeaz if it is not the calendar yeaz: 25a) Is your agency affiliated with any other corporations ? (Yes / No) 25b) If yes, name corporation(s), and explain your agency's affiliation: $ 2,791,400.00 No _._ 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 ~ 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 Snancial 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. $1'L Initials Form Prepared By Title Phone Number Karen McLaughlin Town Director of Human 631 298-4460 Agency Program Contact Title services phone Number Karen McLaughlin Town Director gf Human 631 298-4460 ervices 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 Name TiNe Date CONTRACT AGENCY DISCLOSURE FORM (For 2009 Budget Prceess) Contract AI?ency Information Page 1 of 4 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. ___ _ _ _._ I Suffolk County Office Use OnN Control Number 13799 Date Received ~ i Entered By ~ Reviewed By ~ ~-i Activity Code ~- ,Financial Statement Type: ~- Notes: ~`' Department EXECUTIVE Division Office for the Aging Fund 001 Agency EXE Org 6790 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: 20 Contractor Name: Program Name: Contractor Phone Number Contractor Contact Name: Contractor Street Address: Contractor City Address: Contractor State Address: Contractor Zip Code: 07 Actual : r $189,685 2008 Estimate: ~- $232,701 Town of Southold IIIC Nutrition (631) 298-4460 Extension: ~~ Karen McLaughlin 53095 Main Road, P.O. Box 1179 Southold NY 11971 ,r ;Control~Number ~ Activity Code r 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. $2zo~ ~~5•~6 $ 23( z.~ol•o° 2) Total revenue received directly from State Government for the ~ o r o 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): l o l o _._ _ __ 4) Total revenue received directly from all other Municipalities for the Contract Program. Please identify names and amounts of grant(s): Part 2 -Medicare/Medicaid, Fundraisine and All Other Revenues 5) Total revenue received from Medicare/Medicaid for the Contract Program. 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: Voluntary Contributions/Participant Income 8) Total Contract Program Revenue (Add Lines I - 7) 0 ~-'~ 'I ° I 1 p $llsa ,ssl.oo $ lol s,ooo.oo '$336 $331 7,701.00 Oontrol Number Activity Code ~ Page 3 of 4 Contract Prol?ram Exbenses Part 3 -Direct Contract Program Expenses 2007 Actual 2008 Estimated 9) Direct Contract Program Salaries $ 300,057.00 $ 369,899.00 10) Direct Contract Program Fringe Benefits ~ 22,954.00 I 28,297.00 11) Direct Contract Program Fee for Service 12) Direct Other Contract Program Expenses 13) Total Direct Contract Program Expenses (Add Lines 9 through 12) 209,722.00 239,450.00 $ 532,733.00 r 637,646.00 Part 4 -Administrative Contract Program 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) 1$ 293,055.00 1$ 296,626.00 22,419.00 r-22,692.00 9,094.00 ~ 6,900.00 568.00 $ 326,218.00 19) Total Contract Program Expenses $ 857 , 301.00 $ 963 , 864.00 (Add Lines 13 and 18) 20) Please provide a short description of your Direct Contract Program Expenses: Part 5 -Top 5 Agencv Salaries Exceeding $100,000 Amouot of Salary Charged to the Emalovee Name Emnlovee Title 2007 Salary {ContractProgram 1. ~I Control Number ~ Activity Code Agency Information Part 6 -Financial and Other Aeencv Information 21) Total Agency Support and Revenues 22) Total Agency Expenses 23) Total Agency Net Income/(Loss) (Line 21 minus Line 22) Page 4 of 4 2007 Actual 2008 Estimated $ 31,427,687.00 33,393,933.00 31,843,194.00 36,185,333.00 ($ 415,507.00) $$ 2,79 24) Please indicate your fiscal year if it is not the calendar year: 25a) Is your agency affiliated with any other corporations ? (Yes / No) 25b) If yes, name corporation(s), and explain your agency's affiliation: No 2007 Actual 2008 Estimated 26) Total Agency Administrative Expenses 27) Does your Agency: (Check all that apply, if none apply please check the box marked not applicable) ^ Administer a corps of volunteers ~ 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. s/L Initials Form Prepared By Title Phone Number Karen McLaughlin Town Director of Human Servi es 631 298-4460 Agency Program Contact Title Phone Number Karen McLaughlin Town Director of Human Servi es 631 298-4460 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 best of my knowledge and belief, that all of the information provided on this form is true and correct. Southoln Town Supervisor Name Title Uate