|
Orig Agency Code |
Contract Number | |
|
11000 |
Page 1 of 4
BFM-8 (11/98)
| Contractor Name: | |
| Contractor Contract Person: | Telephone: |
| Expenditure Item | Amount | |
|---|---|---|
| Line 1 | Personal Service | $ |
| Line 2 | Fringe Benefits | |
| Line 3 | General Operating | |
| Line 4 | (Sum of Lines 1, 2 and 3) TOTAL DIRECT COSTS ► | $ |
| Line 5 | Indirect Cost Rate |
% |
| Line 6 | Indirect Cost | |
| Line 7 | Equipment | |
| Line 8 | Purchased Services | |
| Line 9 | (Sum of Lines 4, 6, 7 and 8) TOTAL EXPENSES ► | $ |
| Revenue | Amount | |
|---|---|---|
| 1. | $ | |
| 2. | ||
| Line 10 |
TOTAL REVENUE ► |
$ |
|
Net Budgeted Operating Costs |
Amount | |
|---|---|---|
| Line 11 |
(Line 9 minus Line 10) |
$ |
|
Orig Agency Code |
Contract Number | |
|
11000 |
Page 2 of 4
Contractor Name: _________________________________________________________
| Section 1: Direct Operating Personal Service Listing | ||||
| Title | Social Security Number (if available) |
Annual Salary | % Time Allocated to Program |
Salary Allocated to Program |
|---|---|---|---|---|
|
1. |
Total Personal Service-Direct Operating Salaries (To Budget Summary, Line 1) ► |
$ | ||
|
2. |
Fringe Benefits Rate ► |
% |
||
|
3. |
Total Fringe Benefits |
$ | ||
| Section II: General Operating Expenses | |||||
|---|---|---|---|---|---|
| Item | Cost Item | Amount | Item | Cost Item | Amount |
| 1. | Insurance | $ | 10. | Travel-Staff Out/State | $ |
| 2. | Building Main. & Repair | 11. | Utilities | ||
| 3. | Office Supplies | 12. | Vehicles-Oper. Expenses | ||
| 4. | Program Supplies | 13. | Staff Training | ||
| 5. | Telephone | 14. | Advertising | ||
| 6. | Rent | 15. | Printing | ||
| 7. | Travel-Staff in State | 16. | |||
| 8. | Contractual Svcs | 17. | |||
| 9. | Dues & Subscriptions | 18. |
Total G/O Expenses ► |
$ | |
|
Orig Agency Code |
Contract Number | |
|
11000 |
Page 3 of 4
Contractor Name: ____________________________________________________________
| Section III: Equipment Purchases | ||
|---|---|---|
| Item / Description | Amount | |
| A. | Office Furniture | $ |
| B. | Office Computers | |
| C. | ||
| Total Equipment Purchases
(To Budget Summary, Line 7) ► |
$ | |
| Section IV: Purchased Services | ||
|---|---|---|
| Cost Item | Amount | |
| A. | $ | |
| B. | ||
| C. | ||
| Total Equipment Purchases (To Budget Summary, Line 8) ► |
$ | |
New York State Education Department – Bureau of Fiscal Management
RFP #06-033 Model Transition Program (MTP)
Page 4 of 4
Contractor Name: ____________________________________________________________
|
Estimated |
Number of |
Cost Per |
|---|---|---|---|
Period 1 (06/01/07 – 11/30/08) |
$ |
|
$ |
Period 2 (12/01/08 – 11/30/09) |
$ |
|
$ |
Period 3 (12/01/09 – 11/30/10) |
$ |
|
$ |
Total Contract 3.5 Years |
$ |
|
$ |
Financial Criteria will be scored based on the Cost Per Individual Served for the entire 3.5 year contract period.
Vendor Signature |
|
Date: |
|
Printed Name |
|
||
Company Name |
|
||
Company Address |
|
||