New York State Division of Criminal Justice Services Performance-Based Contracting Quarterly Fiscal Cost Report Program: Implementing Agency: Reporting Period ________________ to ________________ Contract Number: MM/DD/YYYY MM/DD/YYYY Quarterly Final Contract Term: Milestone Annual Goal Unit Cost Number Subtotal (from Appendix B1 (from Appendix B1 (from Appendix Completed Amounts of Contract) of Contract) B1 of Contract) Reimbursement Rate _____% Payment Request CERTIFICATION SUBMIT IN DUPLICATE TO: I certify that the above milestones are made in accordance with the NYS DCJS Alfred E Smith Building pertinent grant, are appropriate to the goals and objectives of the Finance Office 10th Floor project described therein, and are not duplicative of milestones 80 South Swan Street claimed on this or any other grants. Albany, New York 12210 PREPARER’S NAME: GRANTEE: ORIGINAL SIGNATURE REQUIRED NAME DATE PRINAME & TITLE TELEPHONE FISCAL OFFICER: ORIGINAL SIGNATURE REQUIRED EMAIL ADDRESS DATE PRINAME &
New York State Division of Criminal Justice Services Performance-Based Contracting Quarterly Fiscal Cost Report Program: Implementing Agency: Contract Number: Reporting Period ________________ to ________________ MM/DD/YYYY MM/DD/YYYY Contract Term: Quarterly Final Milestone (from Appendix B1 of Contract) Annual Goal (from Appendix B1 of Contract) Number Completed Unit Cost (from Appendix B1 of Contract) Subtotal Amounts Reimbursement Rate _____% Payment Request SUBMIT IN DUPLICATE TO: NYS DCJS Alfred E Smith Building Finance Office 10th Floor 80 South Swan Street Albany, New York 12210 CERTIFICATION I certify that the above milestones are made in accordance with the pertinent grant, are appropriate to the goals and objectives of the project described therein, and are not duplicative of milestones claimed on this or any other grants. PREPARER’S NAME: GRANTEE: ORIGINAL SIGNATURE REQUIRED NAME DATE PRINAME & TITLE TELEPHONE FISCAL OFFICER: ORIGINAL SIGNATURE REQUIRED EMAIL ADDRESS DATE PRINAME &
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