Form 3 Part C Expenditure Report

			Expenditures Report
			H76HA25XX- XXXX.
Budget Year: 5/1/2021 - 4/30/2022																Report ID: XXX
Report Status: Submitted																Last Modified Date: 08/25/2022 02:07 PM
		Recipient Information									Budget Year Award Information
											1. RWHAP Part C Recipient Award Amount							$0
		Official Mailing Address: XXX
											2. RWHAP Part C Approved Carryover Amount							$0
		EIN: XXX
		UEI: XXX
		Preparer's Name: XXX
		Preparer's Title: XXX
		Preparer's Phone: XXX
		Preparer's Fax: XXX
		Preparer's Email: XXX
		Part C Program Total
						Prior FY Carryover							Reporting FY				Total
						Amount		Percent					Amount			Percent	Amount			Percent
		Non-Services
		a. Clinical Quality Management				$0		0.00%					$0			0.00%	$0			0.00%
		b. Administrative				$0		0.00%					$0			0.00%	$0			0.00%
		Non-services Subtotal				$0		0.00%					$0			0.00%	$0			0.00%
		c. Core Medical Services				$0		0.00%					$0			0.00%	$0			0.00%
		d. Support Services				$0		0.00%					$0			0.00%	$0			0%
		Total Service Expenditures				$0		0.00%					$0			0.00%	$0			0.00%
		Total Expenditures (Service + Non-service)				$0		0.00%					$0			0.00%	$0			0.00%
		Total Remaining Unobligated Funds															$0
		Part C Expenditure Categories
						Prior FY Carryover							Reporting FY				Total
						Amount		Percent					Amount			Percent	Amount			Percent
		Core Medical Services
		a. AIDS Drug Assistance Program Treatments				$0		0.00%					$0			0.00%	$0			0.00%
		b. AIDS Pharmaceutical Assistance				$0		0.00%					$0			0.00%	$0			0.00%
		c. Early Intervention Services (EIS)				$0		0.00%					$0			0.00%	$0			0.00%
		d. Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals				$0		0.00%					$0			0.00%	$0			0.00%
		e. Home and Community-Based Health Services				$0		0.00%					$0			0.00%	$0			0.00%
		f. Home Health Care				$0		0.00%					$0			0.00%	$0			0.00%
		g. Hospice				$0		0.00%					$0			0.00%	$0			0.00%
		h. Medical Case Management, including Treatment Adherence Services				$0		0.00%					$0			0.00%	$0			0.00%
		i. Medical Nutrition Therapy				$0		0.00%					$0			0.00%	$0			0.00%
		j. Mental Health Services				$0		0.00%					$0			0.00%	$0			0.00%
		k. Oral Health Care				$0		0.00%					$0			0.00%	$0			0.00%
		l. Outpatient/Ambulatory Health Services				$0		0.00%					$0			0.00%	$0			0.00%
		m. Substance Abuse Outpatient Care				$0		0.00%					$0			0.00%	$0			0.00%
		1. Core Medical Services Subtotal				$0		0.00%					$0			0.00%	$0			0.00%
		Support Services
		a. Child Care Services				$0		0.00%					$0			0.00%	$0			0.00%
		b. Emergency Financial Assistance				$0		0.00%					$0			0.00%	$0			0.00%
		c. Food Bank/Home Delivered Meals				$0		0.00%					$0			0.00%	$0			0.00%
		d. Health Education/Risk Reduction				$0		0.00%					$0			0.00%	$0			0.00%
		e. Housing				$0		0.00%					$0			0.00%	$0			0.00%
		f. Linguistic Services				$0		0.00%					$0			0.00%	$0			0.00%
		g. Medical Transportation				$0		0.00%					$0			0.00%	$0			0.20%
		h. Non-Medical Case Management Services				$0		0.00%					$0			0.00%	$0			0.00%
		i. Other Professional Services				$0		0.00%					$0			0.00%	$0			0.00%
		j. Outreach Services				$0		0.00%					$0			0.00%	$0			0.00%
		k. Psychosocial Support Services				$0		0.00%					$0			0.00%	$0			0.00%
		l. Referral for Health Care and Support Services				$0		0.00%					$0			0.00%	$0			0.00%
		m. Rehabilitation Services				$0		0.00%					$0			0.00%	$0			0.00%
		n. Respite Care				$0		0.00%					$0			0.00%	$0			0.00%
		o. Substance Abuse Services (residential)				$0		0.00%					$0			0.00%	$0			0.00%
		2. Support Services Subtotal				$0		0.00%					$0			0.00%	$0			0.00%
		3. Total Service Expenditures				$0		0.00%					$0			0.00%	$0			0.00%
		Recipient received waiver for 75% core medical services requirement:								Yes
	Legislative Requirements Checklist
	At least 75% of your total award (less CQM and Administrative) must be spent on core medical services.
	When reporting Core Medical Services expenditures, the Total in Section C, Row 1, Column F of the Expenditure Report which includes carryover dollars, must meet the 75% minimum requirement. The exception to this requirement is only for those recipients that requested, and were approved by HRSA, for a Part C Core Medical Services Waiver. To the right is the percentage of your Current Fiscal Year Core Medical Services expenditures divided by your Total Part C Award less the CQM and Administrative expenditures. Please check to make sure this percentage is 75% or greater.																				0.00%
	Clinical Quality Management expenditures should be reasonable.
	To the right is your total CQM Expenditures which includes carryover dollars. Please check to make sure your CQM Expenditures are reasonable																				$0
	No more than 10% of your total award can be spent on Administrative.
	When reporting Administrative expenses, the total (carryover included) must be 10% or less than the award amount. Below is the maximum (Capped Amount) you can spend on Administrative (Part C Grant Award Amount * .10) as well as your Total Administrative expenditures which includes carryover dollars. Please check to make sure your Administrative expenditures do not exceed your Capped Amount.
	Expenditures																				Amount
	Capped Amount																				$0
	Admin Expenditures																				$0
	Public Burden Statement: The purpose of this data collection system is to collect allocations/expenditures information regarding Ryan White HIV/AIDS Program (RWHAP) Parts A, B, C, D grant funding.  HAB will use these data to show the impact of RWHAP funding on the care and treatment of people with HIV in the United States.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this information collection is 0915-0318 and it is valid until 09/30/2023.  This information collection is mandatory (through increased Authority under the Public Health Service Act, Section 311(c) (42 USC 243(c)) and title XXVI (42 U.S.C. §§ 300ff-11 et seq.).  Public reporting burden for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected]