2. Approved Budgets Expenditures can fall into one or more of the following categories: Fee Schedule * ensure RW has a copy Unit Rate * established with RW, documentation required one time or based on historical documentation. Cost Reimbursement * established with RW, documentation required monthly

3. Use approved budget to complete form For each service provided, separate Direct Services from Administrative Costs Provide back-up documentation for each cost reimbursement requested

4. Financial Re Backup Documentation Payroll ledgers, time sheets, mileage reports, invoices, itemized receipts, etc. Highlight charges applicable to the program Separate back up documentation by category for Direct and Administrative Services If you are unsure whether or not the backup you have is acceptable – Ask.

5. Financial Re Financial Reports Report required for each month Submitted Monthly(10 th ) – incomplete or late reports will delay payment Report must include prior Year to Date expenditures Signed and Dated

6. Monthly Fiscal Checklist

8. Must be submitted on company letterhead Provide total amount requested Provide original signature & date, in BLUE ink, on the day it is completed

10. Monthly Financial Report Form Monthly payment request MUST match total on cover letter. All back-up documentation must total amount requested on cover letter Providers to fill in highlighted areas Sign & date in lower left corner

11. MONTHLY FINANCIAL REPORT FORM Mail original and support documentation: Due Date: 10th day of the month Ryan White Part A - Fiscal Services Health Matters Clinic 5550 Venture Dr. Parma, OH 44130 A. Service Provider: (Ph) 216-201.2050 ( FAX) 676.1321 B. Report Period Ending: D. Subgrantee:CCBH Street Address:5550 Venture Dr. City, State Zip:Parma, Oh 44130 C. [ ] Check Box/Marked "F" if Final Report for this Grant.E. Implementing Agency: Health Matters Clinic Street Address:1220 Superior Avenue Monthly Payment Request: $21,700.00 City, State Zip:Cleveland, OH 44106 F. BUDGET COST F. UNITH. APPROVED I. CURRENTJ. PRIOR YTDK. TOTAL YTD L. AVAILABLE RATE BUDGET EXPENDITURES BALANCE Core Medical Services - - Outpatient/Ambulatory Medical Care $70,000.00 $9,000.00$17,000.00$26,000.00 $44,000.00 Primary CareUnit $10,000.00 $1,000.00$2,000.00$3,000.00 $7,000.00 LaboratoryFee $60,000.00 $8,000.00$15,000.00$23,000.00 $37,000.00 Local AIDS Pharmaceutical Assistance ProgramFee $100,000.00 $9,000.00$10,000.00$19,000.00 $81,000.00 Oral Health ServicesFee $15,000.00 $1,200.00$8,000.00$9,200.00 $5,800.00 Medical Case ManagementCR $30,000.00 $2,500.00$10,000.00$12,500.00 $17,500.00 TOTAL COST $215,000.00 $21,700.00$45,000.00$66,700.00 $148,300.00 M. PROGRAM INCOME CURRENT PROGRAM INCOME ACCRUED YTD PROGRAM INCOME ACCRUED * EXPENSES SHOULD BE TRACKED AND DETAILED SUMMARIES WILL BE PROVIDED TO THE GRANTOR AT THE CLOSE OF THE GRANT YEAR. PROGRAM INCOME 1,200.00 - I CERTIFY THAT ALL TRANSACTIONS REPORTED ABOVE HAVE BEEN MADE IN COMPLIANCE WITH ALL APPLICABLE STATUTES AND REGULATIONS AND IN ACCORDANCE WITH THE APPROVED CONTRACT. Report Reviewed and Approved By Internal Use Only: Signature: Phone No.: Fax No.: Date: e-mail: Typed Name and Title: Mail Payment:

12. Direct Services Admin Services Ryan White Part A Medical Case Management- Direct Services Mercy Medical Center Reporting Month: Mercy Medical Center Operating Agency:Program: Medical Case Management Contract Time of Performance: Cost Categories on approved budget Approved BudgetCost incurred This Month Costs Incurred to Date Available Balance Personnel $ - Program Materials $ - - - - Office Supplies $ - - - - Overhead (Phones) $ - - - - Travel $ - - - - Other (Postage/Copies) $ - - - - Total $ - Documentation Samples Service Summary Chart Personnel - Payroll documentation for staff (monthly). Supplies - Provide documentation of costs incurred receipts/chargebacks (monthly). Overhead Phones - Provide bills and receipts or chargebacks (monthly). Travel - Provide a Travel summary for costs incurred (monthly) Other Postage/copies - Provide bills and receipts or chargebacks of costs incurred (monthly). Ryan White Part A Medical Case Management- Administrative Services Mercy Medical Center Reporting Month: Mercy Medical Center Operating Agency: Program: Medical Case Management Contract Time of Performance: Cost Categories on approved budget Approved BudgetCost incurred This Month Costs Incurred to Date Available Balance Personnel $ - Program Materials $ - - - - Office Supplies $ - - - - Overhead (Phones) $ - - - - Travel $ - - - - Other (Postage/Copies) $ - - - - Total $ - Documentation Samples Service Summary Chart Personnel - Payroll documentation for staff (monthly). Supplies - Provide documentation of costs incurred receipts/chargebacks (monthly). Overhead Phones - Provide bills and receipts or chargebacks (monthly). Travel - Provide a Travel summary for costs incurred (monthly) Other Postage/copies - Provide bills and receipts or chargebacks of costs incurred (monthly).

13. Submitting Monthly Invoices & Paperwork Submit via email: In PDF: Cover Page, signed Financial Report, signed Support Documents – payroll, proof of payment bills, etc. If you submit any hard copy, the same documents are required, attention M. Rodrigo In (1) EXCEL FILE: Invoice Support & Data Email all documents to mrodrigo@ccbh.net Email subject line should read: Invoice, Provider Name, Date(April 10, 2012 )

14. 60 day site visit Annual monitoring visit 120 days before end of grant cycle

18. Purpose: Documentation of monthly activities Uniformity among data collection methods Unduplicated data collection across service categories

19. Agencies must submit a data tracking sheet for each service listed on the monthly financial report. Each service category must be recorded on its own service tab. At minimum your data must include the information listed on the approved data tracking sheet.

20. Agency A

23. CD Table of Contents Invoice Data Tracking File (agency-specific) RW Provider Monthly Financial Report Form (agency-specific) Presentation: Ryan White Part A Provider Training: Fiscal Invoicing Federal Resources Folder National HIV/AIDS Strategy National Monitoring Standards Local Resources Folder Part A Service Definitions Funding Exclusions and Restrictions Audit Tools Folders: Program, Fiscal, and Quality Management Agency Responsibilities CCBH Grants Administration Manual

25. Ryan White Part A Program Contacts:  Melissa Rodrigo – Program Supervisor  mrodrigo@ccbh.net (216)201-2001 x1507 mrodrigo@ccbh.net  Kate Burnett – Program Manager  kburnett@ccbh.net (216)201-2001 x1502 kburnett@ccbh.net  Molly Kirsch - Program Manager  mkirsch@ccbh.net (216)201-2001 x1523 mkirsch@ccbh.net  Jen Astronskas – Fiscal Clerk  jastronskas@ccbh.net (216)201-2001 x1525 jastronskas@ccbh.net