Schedule Dmh-2 - Consolidated Quarterly Report - Office Of Mental Health Of New York State
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1
2NEW YORK STATE
Funding State Agency:
SCHEDULE DMH-2
OMH
CONSOLIDATED FISCAL REPORT
AID TO LOCALITIES/
OMRDD
For the Period: July 1, 2009 to June 30, 2010
DIRECT CONTRACT
OASAS
SUMMARY
Page _____
AGENCY NAME:____________________________________
PREPARED BY: _____________________________________________
TELEPHONE: (____) _________________
Please check the box if the preparer changed from the previous submission.
AGENCY CODE:____________________________________
COUNTY NAME & CODE: _______________________(____)
PLEASE CHECK:
ESTIMATED CLAIM ____
FINAL CLAIM _____
Line
COLUMN NUMBER
Cost
No.
ITEM DESCRIPTION
Codes
1 Accounting Method
2 State Contract Number / LGU Contract Number *
00200
3 Program Type
00072
4 Program Code (Program Code Index)
00012
(
)
(
)
(
)
(
)
(
)
EXPENSES
5 Personal Services
18010
6 Vacation Leave Accruals **
18020
7 Fringe Benefits
18030
8 Other Than Personal Services (OTPS)
18040
9 Equipment-Provider Paid ***
18050
10 Property-Provider Paid ****
18060
11 Agency Administration
18080
12 Adjustments/Non-Allowable Costs (Detail Required)
18090
13 Total Adjusted Expenses (Lines 5-11 minus 12)
18999
REVENUES
14 Participant Fees (less SSI & SSA)
46010
15 SSI & SSA
46020
16 Home Relief/Public Assistance
46030
17 Medicaid
46040
18 Medicare
46060
19 Other Third Parties
46070
20 OMRDD Residential Room and Board/NYS OPTS
46080
21 Transportation, Medicaid
46090
22 Transportation, Other
46100
23 Sales: Contract Total
46140
24 Federal Grants (Detail Required)
46160
*
For direct contracts, enter the State Contract Number. For local contracts, enter the local Contract Number, if applicable.
**
OASAS funded service providers cannot report vacation leave accruals for State aid reimbursement.
***
OASAS funded service providers cannot report equipment depreciation for State aid reimbursement.
DMH-2.1
****
OASAS funded service providers cannot report property related depreciation for State aid reimbursement.
Rev.
May 2010
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