POST AWARD CONTRACT DOCUMENTS (COMPLETED BY CONTRACTEE)
1.Budget Revision and Instructions (DAS-57)
2.Report of Contract Expenditures and Instructions (DAS-20a)
3.Contract Progress Report (DAS-45)
4.Report of Expenditures and Request for Reimbursement for Construction Contracts and Certification
NEW JERSEY DEPARTMENT OF HUMAN SERVICES
BUDGET REVISIONS REQUEST (DAS-57)
Instructions
DAS-57
JULY 04
Please refer to Subpart M of the Terms and Conditions for Administration of Contracts for additional instructions for the use of this form.
DAS-57
JULY 04
Reporting Agency and Address
Enter the name and complete mailing address, including the zip code.
Project Title
Enter the title of the Project.
Budget Period
Refer to the Notice of Contract Award or the latest Approved Contract Modification for this information; the Budget Period is the period of time for which a project is funded.
Contract Number
Enter the Contract Number as shown on the signed Notice of Contract Award.
Account Number(s)
Enter the account number or numbers which appear in the Notice of Contract Award.
Revision Number
Requests should be numbered consecutively for each Contract.
Budget Categories and Approved Budget
Enter the amounts by budget category as approved in the Notice of Contract Award, Attachment B or the amounts in the most recent budget request approved by the Department of Human Services.
Requested Changes
Enter the amounts, plus or minus, of the requested changes. On a separate sheet provide complete justifications for all the requested changes. Decreases should be explained in the same detail as increases.
Revised Budget
The Approved Budget column plus or minus the Requested Changes equals the Revised Budget.
Signatures
The budget revision must be signed by the Chief Financial Officer of the agency receiving this Contract.
Approval
A Budget Revision Request shall require the approval of the Contracting Agency’s Program Management Officer and Contract Management Officer. A budget revision will not be considered as valid unless both signatures are on the copy returned to your agency.
DAS-57
JULY 04
New Jersey Department of Human ServicesBUDGET REVISION REQUEST
Attach justification for each category revision on a separate sheet
Reporting Agency / Project TitleAddress / Budget Period
FROM: TO:
City / State / Zip / Contract No. / Account No. / Revision No.
ROUND OFF TO NEAREST DOLLAR
BUDGET CATEGORIES / APPROVED BUDGET / REQUESTED CHANGES* / REVISED BUDGET
Contract Funds / Other Funds / Contract Funds / Other Funds / Contract Funds / Other Funds
A. / PERSONNEL COST
Salaries / Wages
Fringe Benefits
Total
B. / CONSULTANT / PROFESSIONAL SERVICES
COST
Total
C. / OTHER COST CATEGORIES
Office Expense & Related Cost
Program Expense and Related Cost
Staff Training & Education Cost
Travel, Conferences & Meetings
Equipment & Other Capital Expenditures
Facility Cost
Sub-Contracts
Total
Total Direct Cost
Indirect Cost
Total Cost
Less Program Income
NET TOTAL COST
Name of Chief Financial Officer / State Approvals / Yes / No / Date /
Signature
Title / Program Mgmt. Officer
Signature / Date / Contract Management Officer
*Use Plus (+) or Minus (-) signs to indicate additions and subtractions.
DAS-57
JULY 04
NEW JERSEY DEPARTMENT OF HUMAN SERVICES
BUDGET REVISION REQUEST (DAS-57)
Budget /Cost Categories and Elements of Cost
DAS-57
JULY 04
Personnel Cost
Salaries and Wages
Fringe Benefits
Consultant / Professional Services Cost
Accounting and Auditing Services
Any other non-employee related professional services for which a formal
consultant agreement is required
Bookkeeping Services
Office Expense and Related Cost
Advertising for Recruitment and Procurement
Bonding Cost
Data Processing supplies and services
Office Equipment maintenance which are normal maintenance costs compared to
capital improvements
Payroll Services
Postage
Printing and Office Supplies
Telephone
Program Expense and Related Cost(1)
Educational Supplies and Equipment Maintenance
Food for Patients
Kitchen Supplies and Maintenance of Equipment
Medical or Laboratory Supplies or Contract Services (other than consultants)
Medical Supplies and Equipment Maintenance Supplies
Patient Personal care items
Recreation Supplies and Services
Vocational Supplies and Equipment Maintenance
Staff Training and Education Cost
All costs relating to training and continuing education of agency staff
Travel, Conferences and Meetings
Conference and meeting costs
Costs of meals or refreshments served at meetings with volunteers
Employee travel reimbursement
Insurance for Agency Vehicles
Maintenance cost for agency owned vehicles
Reimbursement to volunteers
Equipment and Other Capital Expenditures
Purchase of capital assets including renovations costs
Facility Cost
Depreciation or Use Allowance
Household supplies and Security Services
Insurance and property taxes
Lease or rent payments
License Fees
Maintenance of Building and Grounds
Utilities
Water and Sewer
Sub-Contracts
DAS-57
JULY 04
DAS-57
JULY 04
NOTE: Please refer to the appropriate cost principles for the exact definitions of these cost elements.
(1) Definitions and Cost elements to be included with the applications.
DAS-57
JULY 04
NEW JERSEY DEPARTMENT OF HUMAN SERVICES
INSTRUCTIONS FOR PREPARING THE REPORT OF CONTRACT EXPENDITURES (DAS-20A)
DAS-20a
JULY 04
The Report of Contract Expenditures must be submitted to the New Jersey Department of Human ServicesContracting Agency no later than ten (10) working days immediately following the end of each reporting period. Please refer to Attachment A of the Contract Award and to the Terms & Conditions for Administration of Contracts (Manual) for additional general instructions for the use of this form.
DAS-20a
JULY 04
DAS-20a
JULY 04
Reporting Agency and Address
Enter the name and complete mailing address, including the zip code.
Contract Title
Enter the title of the Contract Award. Refer to item 4 of the Notice of Contract Award Document (GAD).
Contract Number
See item 3 of the GAD.
Contractee Account/Fund Number
Enter your account number, fund number or other identifying numbers which have been assigned to this Contract.
New Jersey Department of Human Services Account Number
Enter the account number or numbers which appear in the Notice of Contract Award Document.
Reporting Period
Enter the month, day and year of the beginning and ending dates of the period for which this report is prepared.
Budget Period
Refer to the Notice of Contract Award Document, item 7, or the latest Approved Notice of Contract Modification for this information. The Budget Period is the period of time for which a project is funded.
Basis of Report
Mark the appropriate box. Refer to Subpart R, Section 18.3 of the Manual.
For reports prepared on a cash basis, expenditures are the sum of actual cash disbursements for goods and services and the amount of cash advances/and payments made to subContractees and contractors.
For reports prepared on the accrual basis, expenditures are the sum of actual cash disbursements and the net increase (or decrease) in the amounts owed by the Contractee for goods and other property received and for services performed by employees, contractors and other payers.
Report Number
Reports should be numbered consecutively within the budget period.
Revision of Report Number
Complete this section only if a revised report of Contract expenditures is being submitted.
Final
Mark this box if the final report of Contract expenditures is being submitted. Final reports are due no later than sixty days after the completion of budget period. All Cash balances shall be returned to the New Jersey Department of Human Services within ten days after submission of this final report.
Budget Categories and Approved Budget
The budget categories have been pre-printed. The Approved Budget amounts should be taken from Attachment B of the GAD. Do not reflect changes to budgeted funds that are requested and have not been approved by the New Jersey Department of Human Services.
Period Expenditures – Whole Dollars
Enter the expenditures by budget category which relates to the reporting period. If program income funds have been approved to be expended during the Contract period, the expenditure of those funds should be included with Contract funds.
Cumulative Expenditures – Whole Dollars
Enter the cumulative expenditures by budget cate- gory from the beginning of the budget period to the end of the budget period. These figures should be computed by adding the current reporting period expenditures to the prior cumulative expenditures.
Total Direct Cost
The total of all budget categories should be en-tered here. If program income funds have been approved to be expended in the budget during this Contract period, they should be reported as expenditures and included in this total.
Indirect Cost
Apply the approved rate to the appropriate base. All indirect cost rates must be approved in the Contract prior to claiming this cost on the Report of the Contract Expenditures.
Total Cost
Total Direct Cost plus applied indirect cost is the total cost.
Less: Program Income
If expenditures of program income funds are reported in the budget categories, the amount program income funds received during the reporting period should be deducted from total direct cost. Program income should be reported on the cash basis, i.e. when funds have been received. Please refer to Subpart K of the manual for definitions and application of program income.
Net: Total Direct Cost
Total cost less applied program income is the net total cost.
Status of Funds
Please complete this section if your Contract has been funded under the Advanced Payment Schedule Method. Indicate total cash received to date less the total cash disbursed to date to calculate the actual cash balance as of the end of the reporting period. This section will be used by the Contracts Management Officer to monitor cash versus expenditures and if necessary, to adjust future scheduled advance payments.
Certification
Complete the certification before submitting the report to the Contracts Management Officer.
DAS-20a
JULY 04
New Jersey Department of Human ServicesREPORT OF CONTRACT EXPENDITURES
Reporting Agency / Contract Number / Reporting PeriodFROM: TO: / Report Number
Address / Contractee Account/Fund Number / Budget Period
FROM: TO: / Revision Report No.
City / NJDHSS Account Number(s) / Basis of Report
CASH
ACCRUAL / FINAL
Contract Title
ROUND OFF TO NEAREST DOLLAR
BUDGET CATEGORIES / APPROVED BUDGET / PERIOD EXPENDITURES / CUMULATIVE EXPENDITURES
Contract Funds / Other Funds / Contract Funds / Other Funds / Contract Funds / Other Funds
A. / PERSONNEL COST
Salaries / Wages
Fringe Benefits
Total
B. / CONSULTANT / PROFESSIONAL SERVICES
COST
Total
C. / OTHER COST CATEGORIES
Office Expense & Related Cost
Program Expense and Related Cost
Staff Training & Education Cost
Travel, Conferences & Meetings
Equipment & Other Capital Expenditures
Facility Cost
Sub-Contracts
Total
Total Direct Cost
Indirect Cost
Total Cost
Less Program Income
NET TOTAL COST
I certify this report is true and correct and all expenditures reported herein have been made in accordance with the terms and conditions of this Contract and are properly reflected in the Contractee’s accounting records. / Accepted By: / Status of Funds:
ContractsYesNo
Management
Officer / Cash received to date$
Less:
Cash disbursements
as of $
Date
Cash Balance
as of $
Date
Name of Chief Financial Officer
Title
Signature Date
Signature / Date
DAS-20a
JULY 04
Budget /Cost Categories and Elements of Cost
DAS-20a
JULY 04
Personnel Cost
Salaries and Wages
Fringe Benefits
Consultant / Professional Services Cost
Accounting and Auditing Services
Any other non-employee related professional services for which a formal \
consultant agreement is required
Bookkeeping Services
Office Expense and Related Cost
Advertising for Recruitment and Procurement
Bonding Cost
Data Processing supplies and services
Office Equipment maintenance which are normal maintenance costs compared to
capital improvements
Payroll Services
Postage
Printing and Office Supplies
Telephone
Program Expense and Related Cost(1)
Educational Supplies and Equipment Maintenance
Food for Patients
Kitchen Supplies and Maintenance of Equipment
Medical or Laboratory Supplies or Contract Services (other than consultants)
Medical Supplies and Equipment Maintenance Supplies
Patient Personal care items
Recreation Supplies and Services
Vocational Supplies and Equipment Maintenance
Staff Training and Education Cost
All costs relating to training and continuing education of agency staff
Travel, Conferences and Meetings
Conference and meeting costs
Costs of meals or refreshments served at meetings with volunteers
Employee travel reimbursement
Insurance for Agency Vehicles
Maintenance cost for agency owned vehicles
Reimbursement to volunteers
Equipment and Other Capital Expenditures
Purchase of capital assets including renovations costs
Facility Cost
Depreciation or Use Allowance
Household supplies and Security Services
Insurance and property taxes
Lease or rent payments
License Fees
Maintenance of Building and Grounds
Utilities
Water and Sewer
Sub-Contracts
DAS-20a
JULY 04
DAS-20a
JULY 04
NOTE: Please refer to the appropriate cost principles for the exact definitions of these cost elements.
(1) Definitions and Cost elements to be included with the applications.
New Jersey Department of Human ServicesCONTRACT PROGRESS REPORT
NOTE: Please type or print clearly. Report due 30 days after the end of each reporting period.
Contract Title / Contract Number / Amount of Contract$ / Contract Period
From / To
Name and Address of Contractee / Date of Report / Period Covered by This Report
From
To / Quarter Covered
1st 3rdFinal
2nd 4th
Objective
LIST BELOW EACH ACTIVITY REQUIRED TO MEET ABOVE STATED OBJECTIVE
/ORIGINAL
ESTIMATEDCOMPLETION
DATE
/ %COMPLETED / DATE
COMPLETED
Name and Title of Reporting Official (Print) / Signature / NJDHSS Review / Date
PAGE OF PAGES
DAS-45
JULY 04
NEW JERSEY DEPARTMENT OF HUMAN SERVICES
REPORT OF EXPENDITURES AND
REQUEST FOR REIMBURSEMENT FOR CONSTRUCTION CONTRACTS
Name of Contractee Organization / Contract No. / Payment Request No.Type of Report
Final Partial
Period Covered by Report
From: To:
Status of Funds: / Approved
Budget / Costs This
Period / Total Costs
To Date
Classification
Demolition and Removal
General Alteration and Renovation
Plumbing
Heating, Ventilation and Air Conditioning
Electrical
Architect and Engineering Fees
Land; Structures
Relocation
Other Costs (Specify);
Total
Less Program Income
State Share
Amount Requested for Reimbursement
% of Physical Completion of Project
CERTIFICATION
I certify that to the best of my knowledge and belief the billed costs and disbursements are in accordance with the terms of the project and that the reimbursement represents the amount due which has not been previously requested and that an inspection has been performed and all work is in accordance with the terms of the award.
Signature of Authorized Certifying Officer / Date Report Submitted
Signature of Authorized Division Official / Date
DAS-5
JULY 04