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    Fiscal Service Administration

    Forms Commonly used by MDH Units
    File Name Date last Updated Description
    Request for Customer Invoice​.pdf
    05/17/23​ ​​Request for Customer Invoice
    Request for Customer Invoice​.doc
    PCA Maintenance Form.xls​
    01/01/23PCA Maintenance Form
    Pay Blocks Forms 
    05/17/23 Pay Blocks - Five Forms
    Signature Card Form.pdf​​​ ​01/17 ​Signature Card Form 

    Full Expense Report.xls​

    ​​Full Expense Report (eff. 01/01/2023)
    ​​Full Expense Report.xls 01/19​
    Full Expense Report ( eff. 01/01/2019)
    Full Expense Report.xls 01/20​ Full Expense Report ( eff. 01/01/2020)
    Full Expense Report.xls​ ​01/21 Full Expense Report (eff. 01/01/2021)
    Half Mileage Expense Report.xls​
    Half Mileage Expense Report (eff. 01/01/2023)
    Half Mileage Expense Report.xls​​​ ​​01/19 Half Mileage Expense Report (eff.01/01/2019)
    Half Mileage Expense Report.xls 01/21 Half Mileage Expense Report ( eff. 01/01/2021)
    Shared Drive- BAA Folder Access.pdf 04/17​ Authorization To Access FSA Shared Drive- BAA Folder
    Shared Drive- BAA Folder Access.doc​
    adjsheet2.xls 05/05 Journal Entry Form
    Tradvreq.xls 05/17/23 Travel Advance Request Form
    Travel-Exception-Reports.doc 11/26/12 Individual Travel Exception Report
    Regireq.doc 05/17/23 Registration Payment Request Form
    WFrPmt1099Inst.doc 12/27/11 Working Fund Request for Payment Form and 1099 Reporting
    WFPmtForm.doc 05/17/23 Request for Working Fund Payment
    Request-for-Payment-AP.doc 05/17/23 Request for Payment - AP

    Contract Forms Commonly used by Human Service Providers

    mdh433.doc 04/12 Condition of Human Service Agreement Statement-MDH 433
    mdh 434.doc 06/12 Assurance of Compliance - MDH 434
    mdh 434.pdf
    mdh 437instr.doc 08/01 Request for Payment - MDH 437 Instructions
    mdh 437instr.pdf
    mdh 437.xls 08/01 Request for Payment - MDH 437 Form
    mdh 437.pdf
    mdh 438instr.doc 08/01 Interim report of actual expense receipts and performances measures - MDH 438 Instructions
    mdh 438instr.pdf
    mdh 438.xls 08/01 Interim report of actual expense receipts and performances measures - MDH 438 Form
    mdh 438.pdf
    Private Provider mdh 432instr.doc 02/97 Human Service Contract Proposal - MDH 432 Instructions
    Private Provider mdh 432instr.pdf
    Private Provider mdh 432.xls 02/97 Human Service Contract Proposal - MDH 432A-H
    Private Provider mdh 432.pdf
    Private Provider mdh 436.instr.doc 05/05 Budget Modifications of Human Services Agreements - MDH 436 Instructions
    Private Provider mdh 436.instr.pdf
    Private Provider mdh 436.a-g.xls 02/97 Budget Modifications of Human Services Agreements - MDH 436A-G
    Private Provider mdh 436.a-g.pdf
    Schedule-of-subvendors.xls 04/12 Schedule of Subvendors
    LHDBudgetinstructFY16.doc​ 05/16 Local Health Dept. Planning & Budget Instructions for FY 2016
    LHDBud​getinstructFY17.doc​​ 05/16​ Local Health Dept. Planning & Budget Instructions for FY 2017
    LHDBudgetinstructFY18.doc​ 05/17​ ​​Local Health Dept. Planning & Budget Instructions for FY 2018
    FY16 Conditions of Award.pdf 05/16​ ​ Local Health Dept. Conditions of Awards
    FY 2016
    FY17 Conditions of
    05/16  Local Health Dept. Conditions of Awards FY 2017
    FY 18 Conditions of Award.pdf 06/17​ Local Health Dept. Conditions of Awards FY 2018
    FY 19 Conditions of Award.pdf ​ ​06/18 ​​Local Health Dept. Conditions of Awards FY 2019
    FY 20 Conditions of Award.pdf​ 06/19​ Local Health Dept. Conditions of Awards FY 2020
    FY 21 Conditions of Award.pdf​ 06/20​ Local Health Dept. Conditions of Awards FY 2021
    Federal-Funding-Accountability-and-Transparency-Act-3-22-12.xls 04/12 Federal Funding Accountability and Transparency Act
    LHD Electronic UFD Budget Package Instructions(4542).doc 02/18 ​LHD Electronic UFD Budget Package Instructions (4542) 
    LHD Electronic UFD Form (4542) .xls​​​​ 10/18 LHD Electronic UFD Budget Form (4542)
    LHDFundSystManual.doc 07/03 Local Health Department Funding System Manual (as of 7/1/03)
    UnliquidatedBalance.doc 10/18 Payment of Unliquidated Accrual Balances
    HSAM_093005 12/05 Human Services Agreement Manual

    MDH Closeout

    Fixed Asset Recon Report.xls​​ 0618 MDH Fixed Asset Recon Report
    GAD Form G-8.pdf​​​​​ 06/18 MDH GAD Form G-8
    Schedule B-1.pdf 06/18 ​MDH Schedule B-1
    ​​Central Office YE Closing Certification.pdf 05/16​ MDH  Central Office Year-End Closing Certification
    Institutions YE Closing ​Certification.pdf​​ ​06/18 MDH Institutions Year- End Closing Certification
    LHD YE Closing Certification.pdf​​ ​06/18 MDH Local Health Departments Year- End Closing Certification
    Comprehensive Annual Financial Reporting.pdf ​​​ 06/18 ​Comprehensive Annual Financial Reporting 
    Master Cost Settlement Adjustment List.xls​ 05/19​ Master Cost Settlement Adjustment List 
    LHD Request For Approval  Notice.doc 05/19​ ​LHD Request For Approval Notice 
    LHD FY20 Closeout Manual.pdf
    LHD FY20 Closeout ​Manual.doc​​
    06/20​ LHD FY20 Closeout Manual

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