Service Delivery Report (Sdr) - Local Government Limited Gaming Impact Fund - Non-Profit Human Service Agencies

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SERVICE DELIVERY REPORT (SDR)
Revised 11/00
Local Government Limited Gaming Impact Fund
NON-PROFIT HUMAN SERVICE AGENCIES
See instructions attached before beginning.
Reporting Entity (Non-profit agency) Name and Address:
County of
Contact Person
Telephone #
1.
Reporting Period:
Year
a. Month
.
OR
b. Calendar Year Quarters:
First
Second
Third
Fourth
2.
Service Delivery Indicators:
a. Personnel and fringe benefit costs for reporting period
$
b. Operating costs for reporting period
$
(Do not include personnel, capital outlay or debt service costs on outstanding debt)
c. Personnel and operating costs for reporting period (a. plus b.)
$
d. Percent of budget utilized for personnel expenses (a. divided by c.)
%
e. Percent of budget utilized for operating expenses (b. divided by c.)
%
f. Fees for services collected during the reporting period
(Only include revenue actually received not accounts receivable. Enter zero
if not applicable.)
g. Net personnel and operating costs (c. minus f.)
$
h. Total number of clients during reporting period
i. Unit cost to agency per client (g. divided by h.)
$
j. Number of clients that are gaming related *
k. Cost of gaming (j. times i.)
$
l. Personnel Cost of gaming (k. times d.)
$
(Enter this amount and the sum of other non-profit Human Service
agency SDR's [Line l.] completed since January 1 on line B. 1.
of the Cost Recovery Form)
m. Operating cost of gaming (k. times e.)
$
(Enter this amount and the sum of other non-profit Human Service
agency SDR's [Line m.] completed since January 1 on line B. 2.
of the Cost Recovery Form)
*
These involve examples where a client or client's family received assistance or is currently receiving assistance
and is employed by a casino or a casino-support business. Also, clients and their families receiving assistance
who are currently unemployed due to casino lay-offs. In addition, persons receiving assistance who traveled
from areas outside the county to seek gaming employment opportunities. These examples are provided to
demonstrate the relationships that must exist to justify impact cost. Other examples may exist.

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