Please complete the this Contract Agency Disclosure Form(s) for your agency and include a copy of your Agency’s 2022 financial statements, IRS Form 990, or Profit/Loss Statement. DO NOT attach a copy of IRS Form 990 -N (e-postcard) as this will not be accepted. Also, please attach a schedule of all full-time employee names, job titles and gross wages (This schedule pertains to your entire agency and not just employees charged to the County funded program(s)).

** Please Note: A Contract Agency’s failure to submit its Disclosure Form(s) and/or any other required document shall constitute noncompliance. A noncompliant contract agency shall not receive funding for any of its programs in the subsequent year’s operating budget.

Contract Agency Information

Each Contract Agency Disclosure Form has its own control number on the top of each page. “Contract Agency Information” contains information related to the contracted program for which information is being requested. Please review this information and correct any inaccurate contract amounts, contact names, contact phone numbers, etc.

Please Note: If you have more than one contracted program, you will need to fill out a Contract Agency Disclosure Form for each program. Do not combine multiple programs onto one Form and please only list amounts relevant to the specific contracted program. If you fail to list only amounts that are specific to the contracted program, this Form will be deemed incomplete and your agency will be deemed noncompliant

Information is being requested for 2022 actual and 2023 estimated contract amounts.If your Agency’s financial records are not maintained on a calendar year basis, please report on the two fiscal years ending in 2022 and 2023. Also, indicate on line 26 the fiscal year being reported on.

Contract Program Revenues

Line Numbers

Part 1 – Government Grants

1

Total amount of revenue received from Suffolk County for Contract Program” – The actual and estimated contract amounts are listed above. If you believe that the amounts listed above are incorrect, please enter the revised amounts for 2022 and 2023 above and on Line 1.

2, 3 & 4

If you received revenue directly from New York State, the Federal Government or another Municipality, please enter the total amount you received on the appropriate line. Also, please indicate the names and amounts of these grants in the space provided.

Part 2 – Medicare/Medicaid, Fund Raising and All Other Revenues

5

"Total revenue received from Medicare/Medicaid for the Contract Program” – Enter the total amount you received from Medicare and/or Medicaid for the Contract Program.

6

“Total fund raising revenue received for the Contract Program” - Enter the amount of fund raising revenue related to the Contract Program.

7

“Total amount of other revenues received for the Contract Program” – Please enter the total amount of any other program revenues (ex: ticket sales, interest, etc.) received by your agency for the Contract Program and indicate the types and amounts.

8

“Total Contract Program Revenue” - Total of lines 1 through 7.

Contract Program Expenses

Line Numbers

Part 3 – Direct Contract Program Expenses

9

“Direct Contract Program Salaries” – Enter the amount of all direct salaries paid to all full and part-time workers whose salaries are charged in full or in part to the Contract Program. Salary amounts entered should be the salary amount actually charged to the Contract Program. Direct salaries are salaries paid to employees who work directly with the Contract Program, (e.g. Counselor, Nurse, Teacher, etc.).

10

“Direct Contract Program Fringe Benefits” – Enter the amount of all fringe benefits related to the full and part-time direct personnel charged to the Contract Program. Fringe benefit amounts should include employer portion of payroll taxes, health and dental benefits, pension benefits, and any other benefits or perks provided to employees of your agency that are paid for through the Contract Program.

11

“Direct Contract Program Fee For Service”” – Enter the amount of expenses for services paid for by your agency, but provided by businesses or individuals outside of your agency (e.g., housekeeping, lab services, phone services, contract labor, maintenance, etc.) for the Contract Program.

12

“Direct Other Contract Program Expenses” – Enter the amount of all other direct expenses related to the Contract Program that were not reported on lines 9, 10, and 11 (e.g., uniforms, equipment, rent, supplies used by direct salaried workers, travel expenses, etc.).

13

“Total Direct Contract Program Expenses” – Total of lines 9 through 12.

Part 4 – Administrative Contract Program Expenses

14

“Administrative Contract Program Salaries”” – Enter the amount of all administrative salaries paid to all full and part-time workers whose salaries are charged in full or in part to the Contract Program. Salary amounts entered should be the salary amount actually charged to the Contract Program. Administrative Salaries are salaries paid to employees who didn’t necessarily work directly with the contract program (ex: CEO, CFO, Bookkeeper, Account Clerk, etc.).

15

“Administrative Contract Program Fringe Benefits” – Enter the amount of all fringe benefits related to the full and part-time administrative personnel charged to the Contract Program. Fringe benefit amounts should include employer portion of payroll taxes, health and dental benefits, pension benefits, and any other benefits or perks provided to employees of your agency that are paid for through the Contract Program.

16

“Administrative Contract Program Fees” – Enter the amount of all legal fees, accounting fees, consulting fees, and other type of professional fees that are related to administrative purposes.

17

“Other Administrative Contract Program Expenses” – Enter the amount of all other expenses related to the administration of the Contract Program being reported on (ex: rent for an administrative office, office equipment & supplies, insurance, etc.).

18

“Total Administrative Contract Program Expenses" – Total of lines 14 through 17.

19

“Total Contract Program Expenses” – Total of lines 13 and 18.

20

Please provide a short description or list of what Direct Contract Program Expenses were charged to the Contract Program.

Line Numbers

Part 5 – Top 5 Agency Salaries Exceeding $200,000

Please list the top five Agency employees who were paid $200,000 or more for 2022. For each individual listed, please provide the employee’s job title, the 2022 salary reported on the employee’s Form W-2 or Form 1099 and the amount (if any) charged to the Contract Program. Also, please attach a separate schedule of all employee names, job titles and 2022 gross wages (Note: This schedule pertains to your entire agency and not just employees charged to the County funded program). If your agency did not pay any employee $200,000 or more for 2022 or is comprised of all volunteers, please select the applicable check box.

Part 6 – Financial and Other Agency Information

21

“Total Agency Support and Revenues” – Enter total agency revenues reported for 2022 and estimated for 2023 that are related to the entire Agency. This amount can be found on your agency’s financial statements on the “Statement of Activities” as Total Support and Revenue. If your agency does not have financial statements, this amount can be found on an income statement, profit/loss statement or on page 1 of IRS Form 990.

22

“Total Agency Program Expenses” – Enter total agency expenses reported for 2022 and estimated for 2023 that are related to the entire Agency. This amount can typically be found on your agency’s financial statements, income statement, or on IRS Form 990.

23

“Total Agency Administrative Expenses”- Enter total agency administrative expenses reported for 2022 and estimated for 2023. Administrative expenses include salaries and related benefits of those employees who perform administrative/clerical (non-technical) activities, and other non-salary administrative expenses incurred to support a project, such as utilities, rent, legal fees, depreciation and amortization. This information can typically be found on your agency’s financial statements on the “Statement of Activities” as total administrative expenses. If your agency does not have financial statements, please add all administrative expenses and enter them on line 23. If you have a question on whether or not an expense is administrative, please call the number provided in the attached letter.

24

“Total Agency Fundraising Expenses” – Enter total agency fundraising expenses reported for 2022 and estimated for 2023.

25

“Total Agency Expenses” – Total of lines 22 through 24.

26

“Total Agency Net Income/(Loss)” – Line 21 minus line 25.

27

If the information provided is not based on a calendar fiscal year, please indicate the fiscal period used for reporting.

28

“Is your agency affiliated with any other corporations? (Yes/No)”– Please indicate whether your agency has either a direct or indirect affiliation with any other corporation(s) or agency(s). If you answered “Yes,” indicate which corporation(s) or agency(s) your agency is affiliated with, and what type of affiliation your agency has with that corporation(s) or agency(s) on line 27b.

29

Please indicate whether your agency administers a corps of volunteers, administered pass through funding, provides education materials or is a food pantry. If none of these describes your agency, please check the box Not Applicable for my Agency”.

“Form Prepared By and Agency Program Contact” – Please provide this information so that we may contact the appropriate person should we have any questions regarding the completion of the form. Also, please provide us with a valid email address.