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Office of Mental Health

New York State Consolidated Budget and Claiming Manual Subject: AC-1171 State Aid Voucher Section: 21
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 State Aid Voucher (AC-1171) is used by the NYS Office of Alcoholism and Substance Abuse Services (OASAS) and the NYS Office of Mental Retardation and Developmental Disabilities (OMRDD) to provide a certified statement of expenditures as a provision of receiving State Aid under Mental Hygiene Law. It also establishes a basis for reconciling advance payments made to Local Governmental Units (LGUs) and direct contract funded service providers.

The NYS Office of Mental Health (OMH) does not require the submission of State Aid Vouchers for advance payments or State Aid claim payments.

The NYS Office of Alcoholism and Substance Abuse Services (OASAS) only requires the submission of State Aid Vouchers by direct contract service providers.

General Instructions

  1. State Aid Vouchers contain the following information relevant to the payee:
    • Identification of the funding State Agency (OASAS or OMRDD),
    • the name and address of the payee,
    • the payee identification number,
    • reference information that will be printed on the check stub to identify the payment to the payee,
    • identification of the period the advance payment or State Aid claim covers, and
    • payee certification that the advance payment requested or State Aid claim is in accordance with all applicable laws or regulations
  2. State Aid Vouchers may be completed using the multi-part form issued by the Office of the State Comptroller or a computer generated facsimile.
  3. Manually completed vouchers must be prepared using blue or black ink or typewritten.
  4. Computer generated State Aid Voucher facsimiles must be identical reproductions of the multi-part form.
  5. All State Aid Vouchers submitted must be legible.
  6. All advance payments requested, expenditures and revenues reported and/or State Aid claimed must be rounded to the nearest whole dollar.

Exception: OMRDD rate-based State Aid programs must use exact calculations.

LGU Instructions

LGUs are required to complete and submit State Aid Vouchers to OMRDD as part of their mid-year and final year-end State Aid claim packages.

Voucher Number

Make no entry.

Originating Agency (Box 1)

Enter the acronym for OMRDD as follows:

NYS OMRDD

Orig. Agency Code

Enter the five (5) digit agency code for the State Agency indicated in box 1 as follows:

OMRDD: 51000

Interest Eligible (Y/N)

Make no entry.

Payment Date (MM) (DD ) (YY)

Make no entry.

OSC Use Only

Make no entry.

Liability Date (MM) (DD ) (YY)

Make no entry.

Payee ID (Box 2) & Additional

Enter the 12 digit Municipality Code assigned to the LGU by the Office of the State Comptroller. Enter the first nine (9) digits of the code in the Payee ID box and the remaining three (3) digits in the Additional box.

Zip Code (Box 3)

Enter the zip code of the city, town or village where the office of the county fiscal officer is located.

Route

Make no entry.

Payee Name, Address, City, State & Zip Code (Box 4)

Enter the title of the county fiscal officer and the street address, city, state and zip code for the county fiscal officer. Do not enter the name of the county fiscal officer.

Payee Amount

Make no entry.

MIR Date (MM) (DD ) (YY)

Make no entry.

IRS Code

Make no entry.

IRS Amount

Make no entry.

Stat. Type

Make no entry.

Statistic

Make no entry.

Indicator-Dept.

Make no entry.

Indicator-Statewide

Make no entry.

Ref./Inv. No. (MM) (DD ) (YY)

Enter information that will identify the payment generated by the voucher. Up to 20 characters (alphabetic and/or numeric) may be used in any combination.

The information entered in this box will be printed on the check stub of any payment generated by this voucher.

Ref./Inv. Date (MM) (DD ) (YY)

Make no entry.

Date Paid (Box 6)

Make no entry.

Check or Voucher No. (Box 6)

Make no entry.

Description of Charges (Box 6)

Enter the period covered by the State Aid claim as follows:

Expenses for the period January 1, 200X through June 30, 200X

or

Expenses for the period 01/01/0X – 06-30-0X

Note: For revised State Aid claims, identify the period covered as described above followed by “Revision # 1”. If there are additional revisions follow the same naming convention using the next number (Revision #2, Revision #3, etc.)

Amount (Box 6)

Enter the total expenses reported in column 2, line 25 of the LGU Fiscal Summary (CQR-3) schedule that will be submitted as part of the mid-year or year-end State Aid claim package.

Total

Enter the total expenses reported in column 2, line 25 of the LGU Fiscal Summary (CQR-3) schedule that will be submitted as part of the mid-year or year-end State Aid claim package.

Less Receipts

Enter the total revenues reported in column 2, line 26 of the LGU Fiscal Summary (CQR-3) schedule that will be submitted as part of the mid-year or year-end State Aid claim package.

Net

Enter the total net operating costs reported in column 2, line 27 of the LGU Fiscal Summary (CQR-3) schedule that will be submitted as part of the mid-year or year-end State Aid claim package.

State Aid Claimed

Enter the total State Aid claimed in column 2, line 25 of the LGU Fiscal Summary (CQR-3) schedule that will be submitted as part of the mid-year or year-end State Aid claim package.

State Aid Program or Applicable Statute (Box 7)

Make no entry.

Payee Certification (Box 8)

Signature in Ink: The State Aid Voucher must be signed by the county fiscal officer (Treasurer, Controller, etc.) or duly authorized representative. The signature must be in blue or black ink. Rubber stamp signatures are not allowed.

Date: Enter the date the State Aid Voucher was signed by the LGU Chief Fiscal Officer or duly authorized representative.

Title: Enter the title of the county fiscal officer or duly authorized representative (Treasurer, Controller, etc.).

Name of Municipality: Enter the county name of the LGU.

For State Use Only Section

Make no entry.

State Comptroller's Pre-Audit Section

Make no entry.

Expenditure Section

Make no entry.

Liquidation Section

Make no entry.

Direct Contract Funded Service Provider Instructions

Direct contract funded service providers are required to complete and submit State Aid Vouchers to OASAS and OMRDD in order to receive advance payments and as part of their mid-year and final year-end State Aid claim packages. The instructions that follow are broken into two (2) sections, one for advance payment voucher completion and one for State Aid claim voucher completion.

Direct Contract Advance Payment Voucher

Voucher Number

Make no entry.

Originating Agency (Box 1)

Enter the acronym for OASAS or OMRDD as follows:

NYS OASAS
NYS OMRDD

Orig. Agency Code

Enter the five (5) digit agency code for the State Agency indicated in box 1 as follows:

OASAS: 53000
OMRDD: 51000

Interest Eligible (Y/N)

Make no entry.

Payment Date (MM) (DD ) (YY)

Make no entry.

OSC Use Only

Make no entry.

Liability Date (MM) (DD ) (YY)

Make no entry.

Payee ID (Box 2) & Additional

Municipalities: Enter the 12 digit Municipality Code assigned to the LGU by the Office of the State Comptroller. Enter the first nine (9) digits of the code in the Payee ID box and the remaining three (3) digits in the Additional box.

Not-for Profits: Enter the service provider's corporate Federal Tax Identification Number. This number mustmatch the Federal Tax Identification Number included in the service provider's fully executed direct contract.

Zip Code (Box 3)

Municipalities: Enter the 12 digit Municipality Code assigned to the LGU by the Office of the State Comptroller. Enter the first nine (9) digits of the code in the Payee ID box and the remaining three (3) digits in the Additional box.

Not-for Profits: Make no entry.

Route

Make no entry.

Payee Name, Address, City, State & Zip Code (Box 4)

If a Municipality or Not for Profit has signed up with the Office of the State Comptroller (OSC) for Electronic Funds Transfer (EFT) payments, all information must be consistent with that provided to OSC or payment will not be paid via EFT.

Municipalities: Enter the title of the municipal fiscal officer and the street address, city, state and zip code for the municipal fiscal officer. Do not enter the name of the municipal fiscal officer.

Not-for Profits: Enter the corporate name, street address, city, state and zip code of the service provider's corporate headquarters.

Payee Amount

Make no entry.

MIR Date (MM) (DD ) (YY)

Make no entry.

IRS Code

Make no entry.

IRS Amount

Make no entry.

Stat. Type

Make no entry.

Statistic

Make no entry.

Indicator-Dept.

Make no entry.

Indicator-Statewide

Make no entry.

Ref./Inv. No. (MM) (DD ) (YY)

Enter information that will identify the advance payment generated by the voucher. Up to 20 characters (alphabetic and/or numeric) may be used in any combination.

The information entered in this box will be printed on the check stub of the advance payment generated by the voucher. For example, an OMRDD 1st quarter advance may be given a reference/invoice number of “OMRDD Jan-Feb 04 Adv”.

Ref./Inv. Date (MM) (DD ) (YY)

Make no entry.

Date Paid (Box 6)

Make no entry.

Check or Voucher No. (Box 6)

Make no entry.

Description of Charges (Box 6)

Enter the contract number and the period covered by the advance payment as follows:

C-000001: Advance payment for the period January 1, 200X through June 30, 200X
or
C-000001: Advance payment for the period 01/01/0X – 06-30-0X Amount (Box 6)

Enter the amount of the advance payment requested.

Note: OASAS providers should Make No Entry; amount will be calculated by OASAS.

Total

Enter the amount of the advance payment requested.

Note: OASAS providers should Make No Entry; amount will be calculated by OASAS.

Less Receipts

Make no entry.

Net

Enter the amount of the advance payment requested.

Note: OASAS providers should Make No Entry; amount will be calculated by OASAS.

State Aid Claimed

Enter the amount of the advance payment requested.

Note: OASAS providers should Make No Entry; amount will be calculated by OASAS.

State Aid Program or Applicable Statute (Box 7)

Make no entry.

Payee Certification (Box 8)

Municipalities: Signature in Ink: The State Aid Voucher must be signed by the municipal fiscal officer (Treasurer, Controller, etc.) or duly authorized representative. The signature must be in blue or black ink. Rubber stamp signatures are not allowed.
Date: Enter the date the State Aid Voucher was signed by the municipal fiscal officer or duly authorized representative.
Title: Enter the title of the municipal fiscal officer or duly authorized representative (Treasurer, Controller, etc.).
Name of Municipality: Enter the county name of the LGU.
Not-for-Profits: Signature in Ink: The State Aid Voucher must be signed by the chief executive officer or duly authorized representative. The signature must be in blue or black ink. Rubber stamp signatures are not allowed.
Date: Enter the date the State Aid Voucher was signed by the chief executive officer or duly authorized representative.
Title: Enter the title of the chief executive officer or duly authorized representative (Treasurer, Controller, etc.).
Name of Municipality: Make no entry.

For State Use Only Section

Make no entry.

State Comptroller's Pre-Audit Section

Make no entry.

Expenditure Section

Make no entry.

Liquidation Section

Make no entry.

Direct Contract State Aid Claim Voucher

Voucher Number

Make no entry.

Originating Agency (Box 1)

Enter the acronym for OASAS or OMRDD as follows:

NYS OASAS
NYS OMRDD

Orig. Agency Code

Enter the five (5) digit agency code for the State Agency indicated in box 1 as follows:

OASAS: 53000
OMRDD: 51000

Interest Eligible (Y/N)

Make no entry.

Payment Date (MM) (DD ) (YY)

Make no entry.

OSC Use Only

Make no entry.

Liability Date (MM) (DD ) (YY)

Make no entry.

Payee ID (Box 2) & Additional

Municipalities: Enter the 12 digit Municipality Code assigned to the LGU by the Office of the State Comptroller. Enter the first nine (9) digits of the code in the Payee ID box and the remaining three (3) digits in the Additional box.

Not-for Profits: Enter the service provider's corporate Federal Tax Identification Number. This number must match the Federal Tax Identification Number included in the service provider's fully executed direct contract.

Zip Code (Box 3)

Municipalities: Enter the 12 digit Municipality Code assigned to the LGU by the Office of the State Comptroller. Enter the first nine (9) digits of the code in the Payee ID box and the remaining three (3) digits in the Additional box.

Not-for Profits: Make no entry.

Route

Make no entry.

Payee Name, Address, City, State & Zip Code (Box 4)

If a Municipality or Not for Profit has signed up with the Office of the State Comptroller (OSC) for Electronic Funds Transfer (EFT) payments, all information must be consistent with that provided to OSC or payment will not be paid via EFT.

Municipalities: Enter the title of the municipal fiscal officer and the street address, city, state and zip code for the municipal fiscal officer. Do not enter the name of the municipal fiscal officer.

Not-for Profits: Enter the corporate name, street address, city, state and zip code of the service provider's corporate headquarters.

Payee Amount

Make no entry.

MIR Date (MM) (DD ) (YY)

Make no entry.

IRS Code

Make no entry.

IRS Amount

Make no entry.

Stat. Type

Make no entry.

Statistic

Make no entry.

Indicator-Dept.

Make no entry.

Indicator-Statewide

Make no entry.

Ref./Inv. No. (MM) (DD ) (YY)

Enter information that will identify the payment generated by the voucher. Up to 20 characters (alphabetic and/or numeric) may be used in any combination.

The information entered in this box will be printed on the check stub of any payment generated by this voucher. For example, an OASAS mid-year claim may be given a reference/invoice number of “OASAS Jan-Jun 04 Clm”.

Ref./Inv. Date (MM) (DD ) (YY)

Make no entry.

Date Paid (Box 6)

Make no entry.

Check or Voucher No. (Box 6)

Make no entry.

Description of Charges (Box 6)

Enter the contract number and the period covered by the State Aid claim as follows:

C-000001: Expenses for the period January 1, 200X through June 30, 200X
or
C-000001: Expenses for the period 01/01/0X – 06-30-0X

Note: For revised State Aid claims, identify the period covered as described above followed by “Revision # 1”. If there are additional revisions follow the same naming convention using the next number (Revision #2, Revision #3, etc.)

Amount (Box 6)

Note: OASAS providers should Make No Entry; amount will be calculated by OASAS.

Quarterly Claim: Enter the total expenses reported in column 3, line 9 of the Agency Quarterly Fiscal Summary (CQR-1) schedule that will be submitted as part of the first, second or third quarter State Aid claim package.

Mid-Year Claim: Enter the total expenses reported in column 3, line 9 of the Agency Quarterly Fiscal Summary (CQR-1) schedule that will be submitted as part of the mid-year State Aid claim package.

Final Year-End Claim: Enter the total expenses reported in the Total column, line 30 of the Aid to Localities and Direct Contracts Program Funding Source Summary (DMH-3) schedule that will be submitted as part of the final year-end State Aid claim package.

Total

Note: OASAS providers should Make No Entry; amount will be calculated by OASAS.

Quarterly Claim: Enter the total expenses reported in column 3, line 9 of the Agency Quarterly Fiscal Summary (CQR-1) schedule that will be submitted as part of the first, second or third quarter State Aid claim package.

Mid-Year Claim: Enter the total expenses reported in column 3, line 9 of the Agency Quarterly Fiscal Summary (CQR-1) schedule that will be submitted as part of the mid-year State Aid claim package.

Final Year-End Claim: Enter the total expenses reported in the Total column, line 30 of the Aid to Localities and Direct Contracts Program Funding Source Summary (DMH-3) schedule that will be submitted as part of the final year-end State Aid claim package.
Less Receipts

Note: OASAS providers should Make No Entry; amount will be calculated by OASAS.

Quarterly Claim: Enter the total revenues reported in column 3, line 13 of the Agency Quarterly Fiscal Summary (CQR-1) schedule that will be submitted as part of the first, second or third quarter State Aid claim package.

Mid-Year Claim: Enter the total revenues reported in column 3, line 13 of the Agency Quarterly Fiscal Summary (CQR-1) schedule that will be submitted as part of the mid-year State Aid claim package.

Final Year-End Claim: Enter the total revenues reported in the Total column, line 31 of the Aid to Localities and Direct Contracts Program Funding Source Summary (DMH-3) schedule that will be submitted as part of the final year-end State Aid claim package.

Net

Note: OASAS providers should Make No Entry; amount will be calculated by OASAS.

Quarterly Claim: Enter the total net operating costs reported in column 3, line 14 of the Agency Quarterly Fiscal Summary (CQR-1) schedule that will be submitted as part of the first, second or third quarter State Aid claim package.

Mid-Year Claim: Enter the total net operating costs reported in column 3, line 14 of the Agency Quarterly Fiscal Summary (CQR-1) schedule that will be submitted as part of the mid-year State Aid claim package.

Final Year-End Claim: Enter the total net operating costs reported in the Total column, line 32 of the Aid to Localities and Direct Contracts Program Funding Source Summary (DMH-3) schedule that will be submitted as part of the final year-end State Aid claim package.

State Aid Claimed

Note: OASAS providers should Make No Entry; amount will be calculated by OASAS.

Enter the total State Aid claimed for the quarterly, mid-year or year-end State Aid claim package.

State Aid Program or Applicable Statute (Box 7)

Make no entry.

Payee Certification (Box 8)

Municipalities: Signature in Ink: The State Aid Voucher must be signed by the municipal fiscal officer (Treasurer, Controller, etc.) or duly authorized representative. The signature must be in blue or black ink. Rubber stamp signatures are not allowed.
Date: Enter the date the State Aid Voucher was signed by the municipal fiscal officer or duly authorized representative.
Title: Enter the title of the municipal fiscal officer or duly authorized representative (Treasurer, Controller, etc.).
Name of Municipality: Enter the county name of the LGU.
Not-for-Profits: Signature in Ink: The State Aid Voucher must be signed by the chief executive officer or duly authorized representative. The signature must be in blue or black ink. Rubber stamp signatures are not allowed.
Date: Enter the date the State Aid Voucher was signed by the chief executive officer or duly authorized representative.
Title: Enter the title of the chief executive officer or duly authorized representative.
Name of Municipality: Make no entry.

For State Use Only Section

Make no entry.

State Comptroller's Pre-Audit Section

Make no entry.

Expenditure Section

Make no entry.

Liquidation Section

Make no entry

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