Contractor Excel Template 41621 | Blank Supp Sapt Stabilization Expense Report With Instructions

Partial file snippet.

Sheet 1: Instructions

	
	
	
		Instructions for completing form SUPP SAPT-EXP-SB and Page 2
		

	
	
		

		

	
	
		Agency Code: 
		Enter the unique five-digit number that identifies the agency and that is used for reporting purposes to OASAS.  Also known as OASAS Provider Number.  The Agency Code can be located on the Attachment B.  This number is the same as the Agency Code number used when submitting Consolidated Fiscal Report documents.
	
	
		Contractor Name:
		Enter the Agency's legal name as reflected on the Attachment B.
	
	
		Claim Type:
		If this is an interim report, check the Interim box.
If this is a final report, check the Final box.
	
	
		Contract Number:
		Enter the contract number shown on the OASAS contract.
	
	
		Program Number w/Index:
		Enter the six-digit Program Number with Index as reflected on the Attachment B.  Report only one (1) Program Number w/ Index per Expense Report.  If the Attachment B includes more than one program, an Expense Report will need to be completed for each.
	
	
		Budget Period:
		Start Date: Enter the start date of the contract as shown on the Attachment B. 
Expiration Date: Enter the expiration date of the contract shown on the Attachment B.
	
	
		Period Covered This Report: 
		This report cannot be submitted more than monthly for allowable costs and should be submitted no later than 45 days after the end of the Expense Report claiming period. 
All Final claims must be submitted no later than 45 days after the expiration date of the contract.
Record the Period that covers the payments of Expenses being submitted for reimbursement.

From: Starting date of period reported
To: Closing date of period reported
	
	
		Approved Budget:
		Enter amounts for the Approved Budget by Budget Categories as reflected in the Attachment B.
	
	
		Submitted Claim:
		Enter amounts expended on the contract, by budget category, incurred during this period that previously were not reported. Claim amounts must be rounded to the nearest dollar.
	
	
		Personal Services: 
		Required Supporting Documentation: If applicable, the Recruitment and Retention Payment Roster must be attached. No additional backup documents are required for Personal Services. See Notes #1 and #2 below.
	
	
		FICA & Fringe Benefits: 
		Required Supporting Documentation: No backup documents are required. See Notes #1 and #2 below.
	
	
		Other Than Personal Services (O.T.P.S):          
		Required Supporting Documentation: Must submit invoices/documentation to account for the total Submitted Claim amount for O.T.P.S.  Contractual services or other consultant documentation must include the vendor invoice(s) containing the person or organization paid, amount, brief description of the goods/services purchased, the date paid, and method of payment. See Notes #1 through #4 below.
	
	
		Equipment: 
		Required Supporting Documentation: Must submit invoices/documentation including receipt or other proof of payment to account for total Submitted Claim amount for Equipment. See Notes #1 through #4 below.
	
	
		Property/Space: 
		Required Supporting Documentation: Must submit invoices/documentation including receipt or other proof of payment to account for total Submitted Claim amount for Property/Space. Ex. Renovation costs. See Notes #1 through #4 below.
	
	
		Agency Administration: 
		Required Documents: No backup documents are required. See Notes #1 and #2 below. 
	
	
		Previously Claimed:
		Enter amounts expended on the contract to date, by budget category, reported in prior periods. Claim amounts must be rounded to the nearest dollar.
	
	
		YTD Claimed:**
		This is a formula that represents the cumulative amounts expended on the contract, by budget category, since the start date.
	
	
		Contractor Authorized Signature:
		Name & Title: 
Enter the printed name and title of the contractor representative authorized to submit this application on the contractor's behalf.
Signature:
The contractor representative must sign expense report.
Date:
Enter the date expense report was completed.
	
	
		Email Address of Preparer:
		Enter email address of the contractor representative who prepared the expense report.
	
	
		Page 2 - R&R Payment Roster:
		Complete the Recruitment and Retention Payment Roster. Refer to the guidelines in the Scope of Work. Include Employee Name, CFR Title Code, Employee Annual Salary, Prior Period Expenditures, and Current Period Expenditures.
	
	
		

		

	
	
		NOTES: 
		1)  Records and documentation must be maintained by the Contractor to support all expenses incurred in performance of this Contract, including those for which no supporting documentation is required for submission as part of the expense report.
	
	
		

		2)  Incorrect/Incomplete Expense Reports or Supporting Documentation will be returned for correction. Until complete documentation is received, no additional payments will be made.
	
	
		

		3)  All Supporting Documents must be identified by the Budget Category it pertains to, such as O.T.P.S., Equipment, or Property/Space and also include Invoice, payment information including date paid and payment method (Check or Credit Card:  if Check include check number; if Credit Card include last 4 digits).
	
	
		

		4)  Invoices and supporting documentation must be equal to or greater than the amount claimed for reimbursement for O.T.P.S., Equipment, and Property/Space. Otherwise, the Expense Report and all supporting documentation will be returned for correction.
	



Sheet 2: SAPT Exp Report

	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
		New York State Office Of Addiction Services And Supports
Supplemental SAPT Expense Report

Email the completed report to COVIDFundsVouchers@oasas.ny.gov with the following subject line:  
Stabilization Expense Report - Enter Contractor Name - Enter Contract Number and Program Number
An incorrect subject line could delay the processing of an expense report

		
	
		Agency Code:
		Contractor Name:
		

		

		

		

		

		

		

		

		

		

		

		

		

		Claim Type
		

	
	
		

		

		Check One Claim Type:
		

	
	
		

	
	
		Contract Number:
		Stabilization
		Budget Period
		

	
	
		Program Number w/ Index*
		Start Date:
		Expiration Date:
		From:
		To:
		

	
	
		

		

		

		

		

		

		

	
	
		* Report one (1) Program Number w/ Index per Expense Report 
** Claim amounts must be rounded to the nearest dollar

		

	
	
		Budget Categories
		Approved Budget
		Submitted Claim **
		Previously Claimed **
		YTD Claimed **
		
	
		Expenses
		

		

		

		

		
	
		Personal Services
		$0 
		$0 
		$0 
		$0 
		
	
		FICA & Fringe Benefits
		$0 
		$0 
		$0 
		$0 
		
	
		O.T.P.S.
		$0 
		$0 
		$0 
		$0 
		
	
		Equipment
		$0 
		$0 
		$0 
		$0 
		
	
		Property/Space
		$0 
		$0 
		$0 
		$0 
		
	
		Agency Administration
		$0 
		$0 
		$0 
		$0 
		
	
		Total Gross Expenses
		$0 
		$0 
		$0 
		$0 
		
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		Total Revenue
		$0 
		$0 
		$0 
		$0 
		
	
		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

		

	
	
		State Aid
		$0 
		$0 
		$0 
		$0 
		
	
		MISREPRESENTATION OF ANY INFORMATION CONTAINED IN THIS REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER NEW YORK STATE LAW.
		
	
		CERTIFICATION STATEMENT
		
	
		I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT, THAT THE INFORMATION FURNISHED IN THIS REPORT HAS BEEN COMPLETED IN ITS ENTIRETY, AND IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER ATTEST TO THE FACT THAT THERE ARE RECORDS AND ALLOCATION WORKSHEETS TO SUPPORT ALL THE INFORMATION CONTAINED HEREIN, IN THE CUSTODY OF THE ABOVE NAMED CONTRACTOR.
		
	
		Contractor Authorized Signature:
		Name & Title:
		Signature:
		Date:
		

	
	
		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		For OASAS Use Only
		

	
	
		Email Address of Preparer:
		

		

		

	
	
		

		Report Reviewed By
		

		

	
	
		

		Date
		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

	
	
		OASAS Form SUPP SAPT-EXP-SB (5/2022)

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...Sheet instructions for completing form supp saptexpsb and page agency code enter the unique fivedigit number that identifies is used reporting purposes to oasas also known as provider can be located on attachment b this same when submitting consolidated fiscal report documents contractor name s legal reflected claim type if an interim check boxif a final box contract shown program windex sixdigit with index only one w per expense includes more than will need completed each budget period start date of expiration covered cannot submitted monthly allowable costs should no later days after end claiming all claims must contractrecord covers payments expenses being reimbursementfrom starting reportedto closing reported approved amounts by categories in expended category incurred during previously were not rounded nearest dollar personal services required supporting documentation applicable recruitment retention payment roster attached additional backup are see notes below fica amp fringe ben...

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Instructions for completing form SUPP SAPT-EXP-SB and Page 2

Agency Code:	Enter the unique five-digit number that identifies the agency and that is used for reporting purposes to OASAS. Also known as OASAS Provider Number. The Agency Code can be located on the Attachment B. This number is the same as the Agency Code number used when submitting Consolidated Fiscal Report documents.
Contractor Name:	Enter the Agency's legal name as reflected on the Attachment B.
Claim Type:	If this is an interim report, check the Interim box. If this is a final report, check the Final box.
Contract Number:	Enter the contract number shown on the OASAS contract.
Program Number w/Index:	Enter the six-digit Program Number with Index as reflected on the Attachment B. Report only one (1) Program Number w/ Index per Expense Report. If the Attachment B includes more than one program, an Expense Report will need to be completed for each.
Budget Period:	Start Date: Enter the start date of the contract as shown on the Attachment B. Expiration Date: Enter the expiration date of the contract shown on the Attachment B.
Period Covered This Report:	This report cannot be submitted more than monthly for allowable costs and should be submitted no later than 45 days after the end of the Expense Report claiming period. All Final claims must be submitted no later than 45 days after the expiration date of the contract. Record the Period that covers the payments of Expenses being submitted for reimbursement. From: Starting date of period reported To: Closing date of period reported
Approved Budget:	Enter amounts for the Approved Budget by Budget Categories as reflected in the Attachment B.
Submitted Claim:	Enter amounts expended on the contract, by budget category, incurred during this period that previously were not reported. Claim amounts must be rounded to the nearest dollar.
Personal Services:	Required Supporting Documentation: If applicable, the Recruitment and Retention Payment Roster must be attached. No additional backup documents are required for Personal Services. See Notes #1 and #2 below.
FICA & Fringe Benefits:	Required Supporting Documentation: No backup documents are required. See Notes #1 and #2 below.
Other Than Personal Services (O.T.P.S):	Required Supporting Documentation: Must submit invoices/documentation to account for the total Submitted Claim amount for O.T.P.S. Contractual services or other consultant documentation must include the vendor invoice(s) containing the person or organization paid, amount, brief description of the goods/services purchased, the date paid, and method of payment. See Notes #1 through #4 below.
Equipment:	Required Supporting Documentation: Must submit invoices/documentation including receipt or other proof of payment to account for total Submitted Claim amount for Equipment. See Notes #1 through #4 below.
Property/Space:	Required Supporting Documentation: Must submit invoices/documentation including receipt or other proof of payment to account for total Submitted Claim amount for Property/Space. Ex. Renovation costs. See Notes #1 through #4 below.
Agency Administration:	Required Documents: No backup documents are required. See Notes #1 and #2 below.
Previously Claimed:	Enter amounts expended on the contract to date, by budget category, reported in prior periods. Claim amounts must be rounded to the nearest dollar.
YTD Claimed:**	This is a formula that represents the cumulative amounts expended on the contract, by budget category, since the start date.
Contractor Authorized Signature:	Name & Title: Enter the printed name and title of the contractor representative authorized to submit this application on the contractor's behalf. Signature: The contractor representative must sign expense report. Date: Enter the date expense report was completed.
Email Address of Preparer:	Enter email address of the contractor representative who prepared the expense report.
Page 2 - R&R Payment Roster:	Complete the Recruitment and Retention Payment Roster. Refer to the guidelines in the Scope of Work. Include Employee Name, CFR Title Code, Employee Annual Salary, Prior Period Expenditures, and Current Period Expenditures.

NOTES:	1) Records and documentation must be maintained by the Contractor to support all expenses incurred in performance of this Contract, including those for which no supporting documentation is required for submission as part of the expense report.
	2) Incorrect/Incomplete Expense Reports or Supporting Documentation will be returned for correction. Until complete documentation is received, no additional payments will be made.
	3) All Supporting Documents must be identified by the Budget Category it pertains to, such as O.T.P.S., Equipment, or Property/Space and also include Invoice, payment information including date paid and payment method (Check or Credit Card: if Check include check number; if Credit Card include last 4 digits).
	4) Invoices and supporting documentation must be equal to or greater than the amount claimed for reimbursement for O.T.P.S., Equipment, and Property/Space. Otherwise, the Expense Report and all supporting documentation will be returned for correction.

New York State Office Of Addiction Services And Supports Supplemental SAPT Expense Report Email the completed report to COVIDFundsVouchers@oasas.ny.gov with the following subject line: Stabilization Expense Report - Enter Contractor Name - Enter Contract Number and Program Number An incorrect subject line could delay the processing of an expense report
Agency Code:		Contractor Name:										Claim Type
												Check One Claim Type:

Contract Number:		Stabilization		Budget Period
		Program Number w/ Index*		Start Date:		Expiration Date:			From:		To:

* Report one (1) Program Number w/ Index per Expense Report ** Claim amounts must be rounded to the nearest dollar
Budget Categories			Approved Budget		Submitted Claim **			Previously Claimed **		YTD Claimed **
Expenses
Personal Services			$0		$0			$0		$0
FICA & Fringe Benefits			$0		$0			$0		$0
O.T.P.S.			$0		$0			$0		$0
Equipment			$0		$0			$0		$0
Property/Space			$0		$0			$0		$0
Agency Administration			$0		$0			$0		$0
Total Gross Expenses			$0		$0			$0		$0

Total Revenue			$0		$0			$0		$0

State Aid			$0		$0			$0		$0
MISREPRESENTATION OF ANY INFORMATION CONTAINED IN THIS REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER NEW YORK STATE LAW.
CERTIFICATION STATEMENT
I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT, THAT THE INFORMATION FURNISHED IN THIS REPORT HAS BEEN COMPLETED IN ITS ENTIRETY, AND IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER ATTEST TO THE FACT THAT THERE ARE RECORDS AND ALLOCATION WORKSHEETS TO SUPPORT ALL THE INFORMATION CONTAINED HEREIN, IN THE CUSTODY OF THE ABOVE NAMED CONTRACTOR.
Contractor Authorized Signature:	Name & Title:					Signature:						Date:

							*For OASAS Use Only*
Email Address of Preparer:
							Report Reviewed By
							Date

OASAS Form SUPP SAPT-EXP-SB (5/2022)

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