DSS-1571 III ADMINISTRATIVE COSTS REPORT Presented By – Natasha Elliott, jean Fecteau, and Ginell rogers, Oeo fiscal analysts

Dss-1571 iii DUE DATE: 10th day of the month following the close of the current month for example: request for October 2016 reimbursement will be due on November 10th Not the 10th business day.

Telephone #(Area Code) new on the dss-1571 III Ein (employer identification number or federal tax id#) is now required on the form.   EIN / Group No Authorized Provider Official Signature Date NCAS -PO No.: Person Responsible for Completion of Report Telephone #(Area Code) 0% Acct / Center Contract Administrator: Telephone Number: Date: Match Acct #

Dss-1571 iii Instructions Top section: Month ending – enter the month and year of the month funds are being requested for reimbursement Contract ID No - included on July tab to prepopulate every month going forward Nc grants# - included on July tab to prepopulate every month going forward Provider Name - enter on July tab and it populates every month going forward address – enter on july tab and it populates every month; ensure that the address you enter on the 1571 is the same address entered on your vendor payment form submitted

Dss-1571 iii Instructions Vendor payment form: When is an updated vendor payment form required???? Change of agency address Change of agency name Change in agency bank account information Change in executive director or signatory Complete form and return to office of state controller

Dss-1571 iii Instructions DSS-1571 III North Carolina Department of Health and Human Services Rev July-16 Division of Social Services DSS-1571 III (Administrative Costs Report ) Month Ending: October-16 Contract ID No: 33669 Address PO Box 2589   NC Grants # 52229 Raleigh, NC 27609 Provider Name: ABC Agency

Dss-1571 iii Instructions Object of Expenditure- A-l are the same expenditure items on your approved Budget Form 225 (cannot be changed)

Section I (1) Object of Expenditure (5) DSS-6844S Budget, Amendments Dss-1571 iii Instructions Section I (1) Object of Expenditure (4) Approved Budget (5) DSS-6844S Budget, Amendments A. Salaries/Wages   0.00 B. Fringe Benefits C. Equipment D. Communications E. Space Costs F. Travel G. Supplies/Material H. Contractual I. Client Services J. Other (List individual) K Administrative Support (4) Approved Budget- Enter your Budget Form 225 line items in column 5 in the month of JULY tab (this will pull the budget into every monthly tab)

Dss-1571 iii Instructions (2) Current expenses - Enter the allowable contract expenditures for the current month

Dss-1571 iii Instructions Ytd Expenses- This column will populate for each reporting period. ( in july current expenses & ytd expenses will be equal).

Dss-1571 iii Instructions (5) dss-6844s budget, amendments - This column is used in the month of July to enter your approved budget. It is not used again unless there is an amendment or budget realignment/change. This column will be zeroes after July, unless an amendment or a budget realignment/change has been approved. Only report the increase or decrease for the line item in this column. This will populate the new approved budget amount in column 4. Column (6) reports the balance of each budgeted line, by subtracting (3) from (4).

Dss-1571 iii example of columns 4, 5, & 6 In this example, we have overspent our supply budget. This form can have no negatives!!!! If you have a negative on the form, you need to back those charges out of the current expenses, and request a budget realignment/change.

Dss-1571 iii Instructions The April reimbursement request submitted in may will be used for the reconciliation of the advance. For example, in may, if the agency has received $200,000 to date and the Ytd expenses are only $191,000, your agency will not receive a payment in may due to advance funds still being on hand. For example, in may, if the agency has received $200,000 to date and the Ytd expenses are only $210,000, your agency will receive a $10,000 reimbursement for May.

Dss-1571 iii Instructions The authorized provider official must sign and date the form in blue ink before scanning a color copy for submission to oeo. Person responsible for completion of report and telephone number can be typed. These 2 people must be different. The person completing the form cannot be the same person authorized to sign as the official.    __________________________________________ ______________  Authorized Provider Official Signature Date _______________  Person Responsible for Completion of Report Telephone# 

In Summary: Fill out the top portion of form 1571 with the date and required agency name and address; Enter budget categories from 225 and breakout the other expenses listed into column 1; Enter "approved budget" into JULY expenditure report tab (tab 1) in column 5 so it populates into column 4;

In Summary (Cont.) Crosscheck the YTD total expenditures on form 1571 (column 3)with YTD total expenditures on form 286 (Column 12); Include the agency’s ein Ensure authorized official signature and date are signed in blue ink and person completing the form section is either typed or signed in blue ink; Submit the dss-1571 iii form along with form 286 to include county reporting page and agency’s 240 report(s).

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