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Office of Mental Health

Document Requirements for Renewal OMH Local Assistance Contracts
with Amendment Numbers Greater Than "0"

(e.g. Contract C00XXXX/1 from the Contract Summary Report by Contract)

Item Non-Residential
Residential Funds Shelter Plus Care

Contract Face Pages 1 & 2

Contract Signature Page X X X
Attachment A-2 (Federally Funded Grants) X1 X1 X1
Attachment A-2(a) (Shelter Plus Care Regulations)     X
Attachment B-4 (Net Deficit Budget) X2 X2 X2
Attachment  C (Work Plan) X X X
Attachment D (Payment and Reporting Schedule) X X X
Attachment E (Certification of Licensed Programs – to be completed by OMH) X3 X3  
Non-Licensed Program Rider/Certification of Compliance (Exhibit A) X4 X4 X4
Residential Program Rider   X  
HCBS Waiver Program Rider PDF Document X5    
Assisted Outpatient Treatment Rider X6 X6  
Vendor Responsibility Questionnaire Leaving OMH site X X X
Proof of NYS Workers’ Compensation (or exemption X X X
Proof of NYS Disability Benefits Insurance (or exemption) X X X
NY Charities Registration (or exemption) X X X
Federal Certification Form 1 X7   X7
Federal Certification Form 2 X7   X7
1 Required if Federal funds are included in contract.
2 Budget is submitted electronically through Consolidated Fiscal Reporting System (CFRS); do not submit paper copy.
3 Required if contract includes licensed programs.
4 Required if contract includes Non-licensed programs. 
5 Required for contracts with OMH Children’s HCBS Waiver Programs only.
6 For outpatient treatment programs involving court ordered population only.
7 Original signed Federal certification forms are required if Federal funds are included in the contract.

September 2016