New York State Department of Probation and Correctional ...
INSTRUCTIONS FOR SUBMITTING ATI PERFORMANCE-BASED CLAIMS FOR PAYMENT
Claims submitted for payment on NYS DCJS Office of Probation and Correctional Alternatives (OPCA) performance-based Alternatives to Incarceration (ATI) contracts must contain the following:
A completed State Aid Voucher with original signatures.
Two sets of Fiscal Cost Reports (OPCA-3269) with original signatures of both the grantee and the fiscal officer.
The Fiscal Cost Report is comprised of 2 pages. The first page, the Performance-Based Contracting Quarterly Fiscal Cost Report, summarizes the achievements of the quarter, and the second page requests a detailed breakdown of the completions summarized on page 1. The following instructions should assist in completing the Fiscal Cost Reports.
Milestone: List each milestone and any outcomes from Appendix B1 of the contract.
Annual Goal: List the target numbers from Appendix B1of the contract.
Number Completed: Provide the total number of completions for each milestone or outcome for the quarter.
Unit Cost: The unit cost is the contractual price per milestone or outcome also from Appendix B1.
Subtotal Amount: A subtotal amount is the number of completions for the quarter multiplied by the unit cost. The Total from page 1 of the Fiscal Cost Report is carried over to the State Aid Voucher.
Reimbursement Rate: This reimbursement rate is found on the Appendix B1 of the contract. It is expressed as a percentage, and this percentage should be applied on the State Aid Voucher after the total is brought forward from the Fiscal Cost Report. There is a box on the voucher to indicate the percentage of state aid claimed.
Page 2 of the Fiscal Cost Report is the Quarterly Detailed Itemization for Performance-Based Contracts of the completions reported on page 1. Required information includes names, NYSID numbers (or dates of birth if NYSID is not known), milestones or outcomes and the dates each milestone or outcome is achieved by each program participant. Additional page 2’s should be completed as needed to provide details for all program participants completing milestones or outcomes during the quarter and for all milestones or outcomes completed.
OPCA staff will periodically request that programs forward copies of cases randomly selected from the claims submitted for payment. These cases will be selected from the Quarterly Detailed Itemization for Performance-Based Contracts (page 2 of the Fiscal Cost Report) or the Quarterly Tracking Log. OPCA staff will review these files to ensure consistency with information submitted for payment.
Completed claims are to be mailed to the NYS DCJS Finance Office, 10th Floor, Albany, NY 12203.
New York State DCJS Office of Probation and Correctional Alternatives
Performance-Based Contracting Quarterly Fiscal Cost Report
|Program: | |
|Implementing Agency: | |
|Contract Number: | | 01/01 – 03/31 10/01 – 12/31 |
| | |04/01 – 06/30 Supplemental |
| | |07/01 – 09/30 |
|Contract Term: | | Interim Final |
| | |
|Milestone |Annual Goal |Number Completed |Unit Cost |Subtotal |
|(from Appendix B1 |(from Appendix B1 | |(from Appendix B1 of |Amounts |
|of Contract) |of Contract) | |Contract) | |
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|Total | |
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|SUBMIT IN DUPLICATE TO: | |CERTIFICATION |
|NYS DCJS | |I certify that the schedules, statements, and the expenses for which payment is requested are |
|Finance Office | |true, correct and complete and were made in accordance with State laws, rules and regulations. |
|Four Tower Place, 10th Floor | | |
|Albany, New York 12203 | | |
|PREPARER’S NAME: | |GRANTEE: | |
| | | |ORIGINAL SIGNATURE REQUIRED |
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|NAME | |DATE | |PRINT NAME & TITLE |
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|TELEPHONE | | | |
| | |FISCAL OFFICER: | |
| | | |ORIGINAL SIGNATURE REQUIRED |
| EMAIL ADDRESS | | | | |
| | |DATE | |PRINT NAME & TITLE |
New York State DCJS Office of Probation and Correctional Alternatives
Quarterly Detailed Itemization for Performance-Based Contracts
| |
|Program: | |Contract #: | |
| 01/01 – 03/31 10/01 – 12/31 | | |
|04/01 – 06/30 Supplemental | | |
|07/01 – 09/30 | | |
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| |Milestones |
| |(from Appendix B1 of Contract) |
| |enter date each milestone is achieved |
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|Last |First |NYSID# | |Milestone |Milestone |Milestone |
|Name |Name |or Date of Birth |Milestone | | | |
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