SFDPH BUSINESS OFFICE

INDIRECT COST RATE INCREASE REQUEST

For Use If Contractor Requests Rate in Excess of 15%

Contractor
Program(s)
1.  The Indirect Expense rate is based on the most recent Financial Statement of the above agency for the fiscal year______
Reason /Justification for Request to Increase: (attach cover letter or memo from agency making request)
2.  Does the proposed rate apply to all DPH contracts / MOU referenced above? / Yes / No
3.  Does this contractor/agency receive funding from more than one DPH Section? / Yes / No
If yes, which DPH Sections? (mark the box to the right of all appropriate sections)
Ambulatory Care-Behavioral Health Services (CYF) / Ambulatory Care-Behavioral Health Services (AOA) / Ambulatory Care -Maternal Child and Adolescent Health / Ambulatory Care-Primary Care (HHS) / Community Health Equity and Promotion (HPS) / Transitions-Housing Services (HUH)
4.  Will the level of contract services be maintained, i.e. do you plan to serve the same number of clients, do you plan to provide the
same amount of service if the direct service amount is decreased? / Yes / No / N/A
If No, write brief explanation here and/or attach additional page. / N/A applies to all cases when direct services are not provided.
I affirm that the costs detailed above accurately reflect the indirect expenses of the program(s) designated above
and are routine costs associated with the program(s).
Signature of Contractor/Provider / Date
For SFDPH Use Only / Recommended for Approval / Recommended for Denial
CDTA: Attach Justification if Denial is Recommended
Signature of CDTA Program Manager / Date
Request Approved / Please Indicate Rate Approved if Lower than Requested / % / Request Denied
Initial of each SOC Director(s) as applicable, or see attached e-mail approval(s)
Ambulatory Care-Behavioral Health Services (CYF) / Ambulatory Care-Behavioral Health Services (AOA) / Ambulatory Care -Maternal Child and Adolescent Health
Ambulatory Care-Primary Care (HHS) / Community Health Equity and Promotion (HPS) / Transitions-Housing Services (HUH)
Date Tracking Sheet Updated ▼
Signature of DPH CFO (if request exceeds 15%)
cc: COOL Quickflow to all appropriate parties / Date Loaded into COOL ▼
Z:\CDTA\Policies And Procedures And Guidelines\Fringe & Indirect Expenses\Indirect Rateincrse Form FINAL Rev 05-26-15.Doc / Revised 05-26-15