AMHI –Financial Reporting Requirement SE-37 Funds

Contractor’s Quarterly Statement of Revenue and Expenses

Contractor:

Contract Year:

Report Period: ☐1st Quarter (Jan-Mar) ☐2nd Quarter (Apr-Jun)

☐3rd Quarter (Jul-Sep)☐4th Quarter (Oct-Dec)

☐Fiscal Year:

Report due within 45 calendar days after the end of each quarter to be submitted for Contractor.

☐ Full Accrual ☐Modified Accrual ☐Cash Basis

Category / AMHI Activity under this Contract
REVENUES
  1. AMHI Health Care Revenues (please specify)
/ ------
(a)
(b)
(c)
  1. Total Revenues

SERVICES AND SUPPORTS EXPENSES
  1. Services and Supports Expenses
When not covered by health insurance or other sources / ------
(a)ENCC/Transition Management / Mobile Crisis and other Clinical Staff costs(salary + benefits)
(b)Promote peer run and peer delivered services that is community based
(development costs, salary+benefits, contract costs)
(c)Housing supports and rental assistance
(eg: temporary housing, security deposit, set-up costs, furniture, etc.)
(d)Supported Employment / Vocational Rehabilitation
(e)Assertive Community Treatment
(f)Habilitative/ RehabilitativeMental Health Treatment Services
(g)Medications
(h)Barriers to Community Living / Engagement Supports for Recovery-Oriented Services
(gym membership, bike, art supplies, personal items,work clothes; transportation not covered by health insurance, etc.)
(i)Guardianship Costs
  1. Incentive Pool and Withhold Adjustments

  1. Other services and supports expenses not included above. (please specify)

  1. TOTAL SERVICES AND SUPPORTS EXPENSES

ADMINISTRATIVE EXPENSES
  1. Contractor

  1. Subcontractor

  1. Other Admin

  1. Total Administrative Expenses

  1. TOTAL EXPENSES

  1. NET INCOME (LOSS)

  1. Beginning Balance (ending balance from last quarterly report) Retained Earnings/Fund Balances

  1. Increase (Decrease) in Retained Earnings/Fund Balance

  1. Other Changes

  1. Balance at End of Current Reporting Period Retained Earnings/Fund Balances

Accounting of Net Income (Loss) Recorded on Line 12:
Contractor shall submit a detailed description of how a net loss (quarterly or fiscal year end)and the impact to the Contractor operations and what fiscal changes were necessary to cover the loss.
Additionally, describe annually how net income will be utilized during the upcoming quarters. This shall include the amount to be retained, the amount to be reinvested, the timeline of reinvestment and a narrative describing how the reinvestment will benefit the AMHI Individuals and support mental health Stakeholders:

Preparer’s Signature Phone Number

Preparer’s Printed NameDate

November2015