Sheet 1: Month+Cumulative Financial Rept

	
	
	
	
	
	
	
	

		


		
Maine Department of 
Health and Human Services
		
Agency:
		


		


		
	

		


		
Program/Service/Component:
		


		


		
	

		


		

 
		
		
Component Period:
		


		

		Enter Start Date of this Budget Component
		

		
through
		

		Enter End Date of this Budget Component
		

		


	
	

		


		
This Reporting Period:
		


		

		Enter the Start Date of the Month
		

		
through
		

		Enter the End Date of the Month
		

		


	
	

		


		
Agreement Number:
		


		


		
	

		


		
CT Number:
		


		


		
	

		


		


		


		


		


		


		


	
	

		
MONTHLY and CUMULATIVE 
REPORT OF REVENUE AND EXPENSES
		
AGREEMENT
		
ACTUAL MONTHLY
		
ACCRUAL CUMULATIVE FOR COMPONENT PERIOD
		
EXPENSES AS % OF COMPONENT PERIOD
	
	

		
BUDGET
		
EXPENSE
		
	

		


		


		


		


		


		


		


		


	
	

		


		
REVENUE SOURCES TO BE COST SHARED
		
	

		


		


		


		


		


		


		


		


	
	

		


		
AGREEMENT FEDERAL REVENUE
		


		


		


		


		


		


	
	

		


		
Federal DHHS Agreement Funds (Enter Amount from Budget Form 1, Line 5 and YTD Amount)
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Federal BLOCK GRANT Agreement Funds (Enter Amount from Budget Form 1, Line 6 and YTD Amount)
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
AGREEMENT STATE REVENUE
		


		


		


		


		


		


	
	

		


		
State DHHS Agreement Funds - GF (Enter Amount from Budget Form 1, Line 9 and YTD Amount)
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
State DHHS Agreement Funds - FHM (Enter Amount from Budget Form 1, Line 10 and YTD Amount)
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
State DHHS Agreement Funds - OTHER (Enter Amount from Budget Form 1, Line 11 and YTD Amount)
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
UNITED WAY REVENUE
		


		


		


		


		


		


	
	

		


		
United Way Funds (Enter Amount from Budget Form 1, Line 12 and YTD Amount)
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
COUNTY/MUNICIPAL REVENUE (Enter Amount from Budget Form 1 and YTD Amount)
		


		


		


		


		


		


	
	

		


		
List Sources Separately below:
		


		


		


		


		


		


	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
PRIVATE CLIENT FEES (Enter Amount from Budget Form 1 and YTD Amount)
		


		


		


		


		


		


	
	

		


		
List Sources Separately below:
		


		


		


		


		


		


	
	

		


		
Third Party Insurance and Self Pay 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Medicare
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
UNRESTRICTED REVENUE  (Enter Amount from Budget Form 1 and YTD Amount)
		


		


		


		


		


		


	
	

		


		
Revenue not for specific use by Donor or funds committed to budget by Agency
		


		


		


		


		


		


	
	

		


		
List Sources Separately below:
		


		


		


		


		


		


	
	

		


		
Agency Commitment to Program
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		
TOTAL COST SHARED REVENUE
		
TOTAL COST SHARED REVENUE
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		
NON COST SHARED REVENUE SOURCES
		
NON COST SHARED REVENUE SOURCES
		
	

		


		


		


		


		


		


		


		


	
	

		


		
MAINECARE (Enter Amount from Budget Form 1, Line 22 and YTD Amount)
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
OTHER RESTRICTED FEDERAL/STATE (Enter Amount from Budget Form 1, Line 23 and YTD Amount)
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
THIRD PARTY IN-KIND (Enter Amount from Budget Form 1, Line 24 and YTD Amount)
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
PROGRAM FEES (Enter Amount from Budget Form 1, Line 25 and YTD Amount)
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
OTHER NON COST SHARED REVENUE (Enter Amount from Budget Form 1 and YTD Amount)
		
	

		


		
List Revenues as shown on Budget Form 1:
		


		


		


		


		


		


	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
TOTAL NON COST SHARED REVENUE
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
TOTAL REVENUE
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
EXPENSE SUMMARY
		
	

		


		


		


		


		


		


		


		


	
	

		


		
PERSONNEL EXPENSES
		


		


		
	

		


		
Salaries/Wages (Enter Amount from Budget Form 2, Line 4 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Fringe Benefits (Enter Amount from Budget Form 2, Line 5 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Third Party In-Kind Personnel (Enter Amount from Budget Form 2, Line 6 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
TOTAL PERSONNEL EXPENSES
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
EQUIPMENT PURCHASES (Enter Amount from Budget Form 2, Line 8 and YTD Amount)
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
SUBRECIPIENT AWARDS (List each subrecipient individually below. Total Agreement Budget column should agree with Budget Form 2, Line 9.)
		


		


		


		


		


		


	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
TOTAL SUBRECIPIENT AWARD EXPENSES
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
ALL OTHER EXPENSES
		
	

		


		
Occupancy - Depreciation (Enter Amount from Budget Form 2, Line 11 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Occupancy - Interest (Enter Amount from Budget Form 2, Line 12 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Occupancy - Rent (Enter Amount from Budget Form 2, Line 13 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Utilities/Heat (Enter Amount from Budget Form 2, Line 14 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Telephone (Enter Amount from Budget Form 2, Line 15 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Maintenance/Minor Repairs (Enter Amount from Budget Form 2, Line 16 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Bonding/Insurance (Enter Amount from Budget Form 2, Line 17 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Equipment Rental/Lease (Enter Amount from Budget Form 2, Line 18 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Materials/Supplies (Enter Amount from Budget Form 2, Line 19 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Depreciation (non-occupancy) (Enter Amount from Budget Form 2, Line 20 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Food (Enter Amount from Budget Form 2, Line 21 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Client-Related Travel (Enter Amount from Budget Form 2, Line 22 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Other Travel (Enter Amount from Budget Form 2, Line 23 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Consultants - Direct Service (Enter Amount from Budget Form 2, Line 24 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Consultants - Other (Enter Amount from Budget Form 2, Line 25 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Independent Public Accountants (Enter Amount from Budget Form 2, Line 26 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Technology Services/Software (Enter Amount from Budget Form 2, Line 27 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Third Party In-Kind (Enter Amount from Budget Form 2, Line 28 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Service Provider Tax (Enter Amount from Budget Form 2, Line 29 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Training/Education (Enter Amount from Budget Form 2, Line 30 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Miscellaneous (Enter Amount from Budget Form 2, Line 31 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Indirect Allocated - G&A (Enter Amount from Budget Form 2, Line 33 and YTD Amount) 
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
TOTAL ALL OTHER EXPENSES
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
TOTAL EXPENSES
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
ADJUSTMENTS
		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
MaineCare Total (Enter Amount from Budget Rider F-1 ASF and YTD Amount) 
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Other Restricted Federal/State  (Enter Amount from Budget Rider F-1 ASF and YTD Amount) 
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Third Party In-Kind Expenses (Enter Amount from Budget Rider F-1 ASF and YTD Amount)
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Program Fees (Enter Amount from Budget Rider F-1 ASF and YTD Amount)
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Subrecipient Awards (Enter Amount from Rider F-1 ASF and YTD Amount Paid to Subrecipients)
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Other Non Cost Share Adjustments (Enter Amount from Budget Rider F-1 ASF and YTD Amount)
		


		


		


		


		


		


	
	

		


		
List Separately:
		


		


		


		


		


		


	
	

		


		
0
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
0
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
0
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
0
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
0
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
TOTAL ADJUSTMENTS
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		


		


		


		


		


		


		


	
	

		


		
CASH REIMBURSEMENT
		
	

		


		


		


		


		


		


		


		


	
	

		


		
TOTAL EXPENSES
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
TOTAL ADJUSTMENTS
		
auto calculated
		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
NET REIMBURSABLE EXPENSES (TOTAL EARNED BY PROVIDER) auto calculated
		


		


		
 $-   
		
 $-   
		
 $-   
		
#DIV/0!
	
	

		


		
Negotiated % (Enter % Agreement State and Agreement Federal funds from Rider F-1 Agreement Settlement Form)
		
0.00%
		
0.00%
		


	
	

		


		
CASH REIMBURSABLE AMOUNT = NEGOTIATED % X NET REIMBURSABLE EXPENSES
		


		


		


		
 $-   
		
 $-   
		


	
	

		


		
Subrecipient Awards
		


		


		


		
 $-   
		


		


	
	

		


		
AMOUNT DUE TO AGENCY  (This amount should agree with monthly invoice.)
		


		


		


		
 $-   
		


		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
I certify that these reported expenses are accurate and allowable for this program.
		


		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
Report completed by:
		


		
Date
		


		


	
	

		


		
 
		


		


		


		


		


		


	
	

		


		
I certify that I have reviewed this report on behalf of the Maine Department of Health and Human Services.
		


		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
DHHS Reviewer:
		


		
Date
		


		


	
	

		


		
Last Updated:  11/9/2020                   Vs. 2021-2
		


		


		


		


		


		


	



Sheet 2: Narrative

	
	
	
	
	
	
	

		
EXPENSE DETAILS Narrative
		
	

		
LINE
		
COLUMN 1
		
COLUMN 2
		
COLUMN 3
		
	

		


		
NAME OF LINE ITEM
		
AMOUNT
		
DETAIL
		
	

		


		
(from Monthly Financial Report) 
		
(Use Narrative Extended if this space is insufficient for required information)
		
	

		
8
		
CAPITAL EQUIPMENT PURCHASES (provide your agency's capitalization policy)
		


		


		
	

		
	

		
9
		
SUB-RECIPIENT AWARDS (provide detailed list)
		


		


		
	

		
	

		
11
		
OCCUPANCY - DEPRECIATION (provide depreciation schedule)
		


		


		
	

		
	

		
12
		
OCCUPANCY - INTEREST
		


		


		
	

		
	

		
13
		
OCCUPANCY - RENT (provide name of landlord and physical address)
		


		


		
	

		
	

		
14
		
UTILITIES/HEAT
		


		


		
	

		
	

		
15
		
TELEPHONE
		


		


		
	

		
	

		
16
		
MAINTENANCE/MINOR REPAIRS
		


		


		
	

		
	

		
17
		
BONDING/INSURANCE
		


		


		
	

		
	

		
18
		
EQUIPMENT RENTAL/LEASE
		


		


		
	

		
	

		
19
		
MATERIALS/SUPPLIES
		


		


		
	

		
	

		
20
		
DEPRECIATION - NON-OCCUPANCY (provide depreciation schedule)
		


		


		
	

		
	

		
21
		
FOOD
		


		


		
	

		
	

		
22
		
CLIENT-RELATED TRAVEL (State Rate $0.44 per mile) Indicate your rate in Column 3
		


		


		
	

		
	

		
23
		
OTHER TRAVEL (State Rate $0.44 per mile) Indicate your rate in Column 3
		


		


		
	

		
	

		
25
		
CONSULTANTS - OTHER (provide detailed information)
		


		


		
	

		
	

		
26
		
INDEPENDENT PUBLIC ACCOUNTANTS
		


		


		
	

		
	

		
27
		
TECHNOLOGY SERVICES/SOFTWARE
		


		


		
	

		
	

		
30
		
TRAINING/EDUCATION
		


		


		
	

		
	

		
31
		
MISCELLANEOUS (should be less than $1,000; use Form 5A for additional details)