Schedule Dmh-3 - Consolidated Quarterly Report - Office Of Mental Health Of New York State

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NEW YORK STATE
FundingState Agency:
SCHEDULE DMH-3
OMH
CONSOLIDATED FISCAL REPORT
AID TO LOCALITIES AND DIRECT CONTRACTS
OMRDD
For the Period: January 1, 2009 to December 31, 2009
PROGRAM FUNDING SOURCE SUMMARY
OASAS
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
TOTAL
No.
ITEM DESCRIPTION
Codes
1 Accounting Method
2 Program Type
00073
3 Program Code (Program Code Index)
00013
(
)
(
)
(
)
(
)
(
)
4 Total Persons Served/Month
00220
5 Total Units of Service
00999
6 Gross Cost/Unit of Service
70999
7 Net Cost/Unit of Service
71999
8
Please Check If Participant Specific Methodology Is Used (OMRDD ONLY)
72999
9
001
001
001
001
001
A. Funding Source Code (Local Assistance)
Index (OMH/OASAS only)
10
Number Persons Served/Month
00260
11
Number Units of Service
00250
12
Total Adjusted Expenses
50999
13
Less Applied Net Revenue
61999
14
Net Operating Costs
62999
15
State Contract Number / LGU Contract Number *
00201
16 B. Funding Source Code
Index (OMH/OASAS only)
17
Number Persons Served/Month
00261
18
Number Units of Service
00251
19
Total Adjusted Expenses
50998
20
Less Applied Net Revenue
61998
21
Net Operating Costs
62998
22
State Contract Number / LGU Contract Number *
00202
23 C. Funding Source Code
Index (OMH/OASAS only)
24
Number Persons Served/Month
00262
25
Number Units of Service
00252
26
Total Adjusted Expenses
50997
27
Less Applied Net Revenue
61997
28
Net Operating Costs
62997
29
State Contract Number / LGU Contract Number *
00203
D. Totals From A-C Above
30
Total Adjusted Expenses
51999
31
Less Net Revenue
63999
32
Net Operating Costs
52999
* For direct contracts, enter the State Contract Number. For local contracts, enter the local Contract Number, if applicable.
DMH-3
Rev. October 2009

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