Spreadsheet: 02955ebf-ee82-4c57-9e0c-0c0ecd08ca78
Sheet: Sheet1

ERR Form Updated 12/13/10 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4
COLORADO DEPARTMENT of PUBLIC HEALTH and ENVIRONMENT
FAMILY PLANNING EXPENDITURE / REVENUE REPORT
AGENCY NAME:
PERIOD:                    January 1 - June 30, _____                July 1 - December 31, _____
COMPLETED BY AND PHONE#: |  |  | DATE:
EXPENDITURES
NOTE: Your expenditures in the CDPHE-WHU Funding column should be based on (and match) the total billed in the July 2010 - Dec 2010 cost reimbursement forms.
 |  | Column (A) | Column (B) | Column (C)
 |  | CDPHE WH Funding (Federal Title X,        State, & CFPI) | Family Planning Program - (Non-CDPHE WH funding) | Combined Total
Personal Services (salary and fringe) |  | 0 | 0 | 0
Contractual Services |  | 0 | 0 | 0
Operating Expenses
Equipment (only include single items costing > $5,000) |  | 0 | 0 | 0
All other operating expenses |  | 0 | 0 | 0
Subtotal Operating Expenses |  | 0 | 0 | 0
Total Direct Costs |  | 0 | 0 | 0
Indirect Costs |  | 0 | 0 | 0
Administrative Costs (CFPI) - (maximum 10% CFPI Expansion) |  | 0 | 0 | 0
TOTAL EXPENDITURES |  | 0 | 0 | 0
In-kind (donations) |  | 0 | 0 | 0
TOTAL COSTS |  | 0 | 0 | 0
REVENUE BY FUNDING SOURCE
NOTE: Your revenue in the CDPHE-WHU Funding column should be based on (and match) the total billed in the July 2010 - Dec 2010 cost reimbursement forms.
 |  | CDPHE WH Funding | Family Planning Program - (Non-CDPHE WH funding) | Combined Total
CDPHE - Women's Health Title X / State Family Planning Contracts |  | 0 |  | 0
CDPHE - Women's Health Colorado Family Planning Initiative Contracts |  | 0 |  | 0
* CDPHE -Chlamydia Testing Funds (ONLY for Childrens, El Paso, Larimer, Weld & Teller) |  | 0 |  | 0
Client fees |  |  | 0 | 0
Client donations |  |  | 0 | 0
Medicaid |  |  | 0 | 0
State Children's Health Ins (CHP+) |  |  | 0 | 0
Local government-County and City grants and contracts |  |  | 0 | 0
**In-kind (Other Donations, Volunteers)) |  | 0 | 0 | 0
Other public health insurance (TRICARE/CHAMPUS, CHAMPA) |  |  | 0 | 0
Private health insurance |  |  | 0 | 0
Temporary Assistance for Needy Families (TANF) |  |  | 0 | 0
Other (specify below revenue such as private grants, fundraising, MCH, Social Service Block grant, Medicare, WWC, etc)
Other 1: |  |  | 0 | 0
Other 2: |  |  | 0 | 0
Other 3: |  |  | 0 | 0
TOTAL |  | 0 | 0 | 0
Unspent Funds - This Period      (Note: The CDPHE WH Funding column should be 0.) |  | 0 | 0 | 0
Unspent Funds - Prior Periods   (Note: The CDPHE WH Funding column should be 0.) |  | 0 | 0 | 0
Balance Unspent Funds             (Note: The CDPHE WH Funding column should be 0.) |  | 0 | 0 | 0
Has your agency used Title X funds to purchase any single piece of equipment valued at $5,000 during this period?    ___ Yes    ___ No
IMPORTANT: PLEASE ENTER ALL AMOUNTS INTO THIS FORM AS WHOLE DOLLARS.  DO NOT INCLUDE ANY CENTS ON THIS REPORT.
*CDPHE - Chlamydia Testing Funds to be entered ONLY by agencies who do NOT use the CDPHE lab: [NAME]'s, El Paso, Larimer, Weld & Teller.
** If your agency uses the CDPHE lab and got a credit for Chlamydia testing, DO NOT enter he in-kind value of those tests here.  CDPHE will add the amount of your credit into the In-Kind line after you submit the ERR to CDPHE.
[NAME] your completed Excel file to [NAME] at [EMAIL] by the end of the day January 27, 2011.
Contact [NAME] at [EMAIL] or (303) 692-2431 with any questions about the ERR forms and requirements.