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Office of Mental Health

New York State Consolidated Budget and Claiming Manual Subject: CBR-i Agency Identification and Certification Statement Section: 11
For the Periods:
January 1, 2009 to December 31, 2009
July 1, 2009 to June 30, 2010
Issued: September 9, 2009

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The CBR-i Consolidated Budget Report schedule is used to capture agency identifying data for county operated and not-for profit service providers operating programs funded and/or certified by one (1) or more of the DMH State Agencies.

Note: This is the only budget schedule with the agency address. Please ensure that this schedule is included in your submission.

For the Period

Enter the beginning and ending dates of the budget period covered by the document.

Agency Name

Enter name of the organization (service provider) operating the reported program(s).

Agency Address

Enter the address of the organization operating the reported program(s).

Note: Please check the box if the organization's headquarters/central administrative office has changed since the last reporting period.

Agency Code

Enter the five (5) digit code assigned to the organization operating the reported program(s).

County Name

Enter the county where the organization's headquarters/central administrative office is located.

OMH Note: Service providers located in the five (5) boroughs of the City of New York (Bronx, Kings, New York, Queens and Richmond) should use the county name “New York” on their CBR-i.

County Code

Enter the two (2) digit county code associated with the county where the organization's headquarters/central administrative office is located. Please see Appendix C of this manual and the Consolidated Fiscal Reporting and Claiming Manual (CFR Manual) for a list of New York State counties and their associated county codes.

OMH Note: Service providers located in the five (5) boroughs of the City of New York (Bronx, Kings, New York, Queens and Richmond) should use county code “31” on their CBR-i.

Type of Ownership

Enter the organization's type of ownership:

Not-for-Profit: A group, institution, or corporation formed for the purpose of providing goods and services under a policy where no individual (e.g., stockholder, trustee) will share in any profits or losses of the organization. Profit is not the primary goal of not-for-profit entities. All income and earnings will be used exclusively for the purpose of the corporation and no part shall inure to the benefit of any private individual, firm or corporation.

Proprietary: A privately or publicly owned entity operated for profit.

Governmental: An entity operated by a State, County or Municipality.

Person to Contact

Enter the name, title, email address phone number and fax number of the person that can answer questions about the information contained in the document.

Note: Please check the box if the person to contact has changed since the last reporting period.

State Agency(ies)

Indicate the NYS Department of Mental Hygiene (DMH) State Agency(ies) that fund(s)/Certify(ies) the reported program(s). The DMH State Agencies are the Office of Alcoholism and Substance Abuse Services (OASAS), Office of Mental Health (OMH) and the Office of Mental Retardation and Developmental Disabilities (OMRDD).

Date Prepared

Enter date this document was completed.

Number of Pages

Enter the total number of pages submitted including attachments to the Consolidated Budget Report (CBR).

Comments or questions about the information on this page can be directed to the Community Budget & Financial Management (CBFM) Group.