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The following is
a summary of the forms required from all grantees receiving funds
from the State of Maryland, Department of Health and Mental Hygiene
(DHMH) awarded through the Core Service Agencies
(CSA's).
Form
432:
This form is the standard
application to become a vendor for a health related human services
program funded in whole or in part by the Mental Hygiene
Administration (MHA). The form contains vendor information,
the program budget page, the program estimated performance measures
page, supporting schedules for salary costs, consultant costs,
equipment costs, purchase of service costs, and the anticipated
sources of funding page. This form is submitted during the
Request for Proposals (RFP) period preceding each fiscal
year.
Form
436:
This form is used to
submit a budget modification requesting approval for unbudgeted
expenditures or over-expenditures in controlled line
items. This form must be submitted no later than April
15th. Detailed instructions are contained in the Human
Services Agreement Manual (Grant Manual) starting on Page
65.
Form
437:
This is also known as the
request for payment form and is to be submitted based on a preset
schedule. The form consists of three parts, only Part A is
used by vendors receiving funds from MHA.
Form 438:
This
form is a required submission for all vendors. The actual
expenses, receipts, and performance measures reported on this form
will be subject to analysis prior to making the relevant subsequent
payment (via form 437). This form is also submitted according
to a schedule. It consists of three sections, one for vendor
information, one for budget and actual expenditure information, and
one for receipt information.
Form 440:
All
expenditures, income, and performance measures relating to human
service agreements or contracts are reconciled annually.
Vendors are to submit this information on the Annual Report (Form
440). This form is due no later then July 15th. All
unbudgeted line items, expenditures over tolerances in controlled
line items and shortfalls in fee collections must be justified in
writing to be considered for possible allowance.
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