Monthly Data & Payment Report (SFN 269) 650-25-85-01

(Revised 1/1/07 ML#3061)

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The Monthly Data & Payment report (SFN 269) (235 kb) is available as a PDF fillable form and in the web-based SAMS 2000 custom report section. The report is due at Aging Services Division no later than thirty days after the end of the monthly service period. The State will make payment within thirty days after receipt of the Monthly Data & Payment Report and other required reporting, except no payment will be made until the reimbursement and reporting have been approved by the State. The State will not make any advanced payments before performance by the contractor.  

 

The SAMS 2000Agency Summary Report, generated through the web-based SAMS system, must be submitted with the Monthly Data & Payment Report (SFN 269).

 

Instructions for Completion of the Monthly Data & Payment Report (SFN 269)  

 

SECTION I:  IDENTIFYING DATA (to be completed by the Contract Entity)

 

Legal Entity Name, Address, City/State/Zip: Complete as stated in the Contract.  

 

Name/Title/Date:  By typing respective name/title/date into fields, the Contract Entity certifies compliance with the match requirement as state in the Contract. Enter the Title/Date. The completed form must be printed, signed, and submitted to Aging Services Division for payment.

 

Service Period:  Record the service period for which the payment is requested. Recording must include the month, days, and a four-digit year.

 

Contract Number:  Record the contract number as it appears on the Contract.

 

Aging Services Division will complete the following information:

 

ASD File Number:  Aging Services Division will record the ASD file number. The number is an internal tracking number.

 

Vendor Number:  Aging Services Division will record the Vendor Number. The number is an internal number necessary for payment purposes.

 

SECTION II:  PROGRAM & FISCAL DATA (to be completed by the Contract Entity)

 

Row A - Nutrition Education: Record the number of units provided during the identified service period and the dollar value associated with the service.

 

Row B - Nutrition Counseling: Record the number of units provided during the identified service period and the dollar value associated with the service.

 

Row C - Volunteers: Record the number of hours provided during the identified service period and the dollar value of the hours.

 

Row D - Unduplicated Individuals Served: Represents the cumulative number of persons served from the beginning of each federal fiscal year (October 1). The information can be generated using a SAMS 2000 Agency Summary Report.  Attach this report to the Monthly Data & Payment Report (SFN 269).

 

Row E- Number of Eligible Units Provided: Record the number of eligible service units provided for each service listed in the Contract for the identified service period.  The information can be generated using a SAMS 2000 Agency Summary Report. Attach this report to the Monthly Data & Payment Report (SFN 269).

 

Row F- Required Match Expended: Record the amount of required match that will be expended for each of the contracted services for the identified service period. To calculate the amount of required match for each service, multiply the number of contracted units provided times the fixed contracted rate to determine the Federal/State payment amount. Divide the Federal/State payment by 85% and multiply by 15%. (Contracted units provided x the fixed contracted rate = Federal/State payment ÷ 85% x 15% = required match).

 

Row G - Program Income:

 

Row G1 - Received:  Record the amount of program income received for each service for the identified service period.

 

Row G2 - Expended: Record the amount of program income expended for each service for the identified service period. Program income can only be expended for the service from which it was generated except for congregate and home-delivered meals where it can be expended for either service.

 

Row H - Additional Local: Record the amount of anticipated additional local funds expended for each service for the identified service period. Additional funds may be required to meet all program costs.

 

Aging Services Division will complete the following section:

 

SECTION III: PAYMENT  

 

Row A - Federal Fixed Contracted Rate: Listed is the fixed contracted rate per unit of service for each of the services. If a service name is not pre-printed in the column headings, Aging Services Division will record the contracted rate for the service purchased.

 

Row B - Federal/State Payment: The amount of the federal/state payment will be recorded for each of the contracted services for the service period based on the number of units served, the fixed contracted rate, and the contract fund balance.

 

Row C - NSIP Payment: The amount of payment will be determined based on the number of meals served during the preceding federal fiscal year and the amount of the State NSIP award. NSIP payments will be disbursed upon receipt from the Federal government. The line will remain blank until funds are disbursed.  

 

Row D - Previous Balance: The contracted fund balance amounts will be recorded for each of the services. The balance(s) represent the amount of funds that remain on the prior monthly payment form.

 

Row E - Balance After Payment: After payment is made for the identified service period, the contracted federal fund balance will be recorded.

 

The additional coded sections are for the Department of Human Services internal use.

 

At the end of the contract period:  

 

A Contract Entity may not be able to record all of the funds expended by the time the form is due for payment. If a Contract Entity has expended funds (i.e. program income, required match, and additional local) that have not been recorded throughout the monthly submittals, an additional Monthly Data & Payment Report may be submitted.  Identify the additional form by indicating “Additional Expenditures” in the Service Period box.