MFP Capacity Building Invoice Form

MFP Capacity Building Monthly Report and Invoice Form

This invoice form is to reimburse your organization for work completed as part of the "MFP Capacity Building Grant" Project (“the Project”) as outlined in the Grant Agreement your organization has entered into with Public Consulting Group (PCG). PCG is the Fiscal Agent acting on behalf of the Colorado Department of Health Care Policy and Financing.
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By the 15th calendar day of each month, Grantees must submit monthly report and any request for reimbursement for the previous month's work. If there are extenuating circumstances requiring late submission, HCPF will determine how to proceed on a case by case basis.

In order to complete this invoice form please populate the following sections according to the instructions found below:
1. Contact Information;
2. Grantee Organization Information;
3. Deliverables
4. Monthly Reporting; and
5. Expense Information for Payment.
If you require assistance in completing the invoice, please reach out to COARPA@pcgus.com, or call 857-302-7425.

The Grant Agreement budget is summarized below:

The Grantee will be reimbursed for expenses paid with supporting documentation. Payments will be capped at the amounts included in the budget in Grant Application approved by CO HCPF, as included in herein Exhibit C and subject to the limitations outlined in Exhibit A §3 for the responsibilities outlined in Exhibit A §4. The Grantee will submit for reimbursement at most once per month, but no later than 60 days after payment of the expense. The final invoice must be submitted no later than May15th, 2025.

Contact Information

This is who PCG will contact if needed to resolve questions about the invoice submission.
Invoice Contact First Name*
First Name
Invoice Contact Last Name*
Last Name
Invoice Contact Email*

Confirmation EmailPlease re-enter for verification
Invoice Contact Phone Number*
Please enter a valid phone number.

Grantee Organization Information

PCG will use this information to verify the organization is eligible for payment under this grant award.
Grantee Organization Name*
Grant Agreement Number*
Invoice Month*
The month when the activities were completed
Invoice Address*
Invoice Address 2
Invoice City*
Invoice State*
Invoice Zip Code*

Deliverables
Work Plan

The work plan is due within 14 days of contract effective date and approval of the work plan must be attached to your first invoice.
Is this your first invoice submission?*

YesNo
Please upload CO HCPF email approval of your work plan:*

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Mid-Year Project Report

The mid-year project report is due November 15, 2024
Is your mid-year Project Report due with this invoice?*

YesNo
Please upload your mid-year project report. The template was included with your grant agreement.*

File Name: Organization_Midyear Report
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Please upload documentation that your sam.gov registration is still active. *

A screenshot of the SAM ID number and expiration date is preferred
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Final Report

Your final project report is due to the Department at the time of the last invoice or on the Project End Date (4/30/2025), whichever is sooner. Approval of the final project report is required with submission of your final invoice.
Is this your final invoice?*

YesNo
Please upload CO HCPF email approval of your final report:*

File Name: Organization_FinalReport
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Monthly Report
Please list any education or outreach you completed this month to build awareness pf opportunities for community living. (This may include training, stakeholder engagement, or development of new resources.)*
You may mark N/A if the question is not relevant to your grant activities for this month.
Please list any technology purchase this month and provide a brief detail of how this purchase extended to your grant goals. *
You may mark N/A if the question is not relevant to your grant activities for this month.
Please list any activities completed this month that support access to and streamlining transition services and support. *
You may mark N/A if the question is not relevant to your grant activities for this month
Please list the number of participants serviced this month:*
Is there anything else you would like to share about your progress this month? If yes, please use the space below:

Expense Information for Payment

Please document allowable expenses incurred in accordance with the approved budget and upload supporting documentation. Please have the name of your file (pdf, word and/or excel document) start with the expense category you are requesting reimbursement for. This will assist us in reviewing your invoice and locating each document across expense categories. Please note that expenses must be submitted for reimbursement within 60 days of occurrence.
Do you have a request for reimbursement to submit this month?*

YesNo
Please upload Detailed Expense Report and continue through the form to request reimbursements by budget category*

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Personnel

Invoiced items should align with this budget category and the narrative/justification for requested funds in the Grant Application Budget Workbook, also identified in the Grant Agreement Exhibit C
Do you have Personnel expenses to submit on this invoice?*

YesNo
Estimated reimbursement for Personnel expense:*
Please attach Personnel supporting documentation, which should include a payroll report or other document to substantiate invoiced personnel expenses and to demonstrate that this funding is not supplanting other funding:*

File Naming: Personnel_Document Name
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Fringe Benefits

Invoiced items should align with this budget category and the narrative/justification for requested funds in the Grant Application Budget Workbook, also identified in the Grant Agreement Exhibit C
Do you have Fringe Benefits expenses to submit on this invoice?*

YesNo
Estimated reimbursement for Fringe Benefits expenses*
Please attach Fringe Benefits supporting documentation, which should reasonably substantiate invoiced expenses and demonstrate that this funding is not supplanting other funding:*

File Naming: Fringe_Document Name
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Travel

Invoiced items should align with this budget category and the narrative/justification for requested funds in the Grant Application Budget Workbook, also identified in the Grant Agreement Exhibit C
Do you have Travel expenses to submit on this invoice?*

YesNo
Estimated reimbursement for Travel expense*
Please attach Travel supporting documentation, which should reasonably substantiate invoiced expenses:*

File Naming: Travel_Document Name
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Training

Invoiced items should align with this budget category and the narrative/justification for requested funds in the Grant Application Budget Workbook, also identified in the Grant Agreement Exhibit C
Do you have Training expenses to submit on this invoice?*

YesNo
Estimated reimbursement for Training expense*
Please attach Training supporting documentation, which should reasonably substantiate invoiced expenses:*

File Naming: Training_Document Name
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Equipment

Invoiced items should align with this budget category and the narrative/justification for requested funds in the Grant Application Budget Workbook, also identified in the Grant Agreement Exhibit C
Do you have Equipment expenses to submit on this invoice?*

YesNo
Estimated reimbursement for Equipment expense*
Please attach Equipment supporting documentation, which should reasonably substantiate invoiced expenses*

File Naming: Equipment_ Document Name
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Supplies

Invoiced items should align with this budget category and the narrative/justification for requested funds in the Grant Application Budget Workbook, also identified in the Grant Agreement Exhibit C
Do you have Supplies expenses to submit on this invoice?*

YesNo
Estimated reimbursement for Supplies expense*
Please attach Supplies supporting documentation,which should reasonably substantiate invoiced expenses:*

File Naming: Supplies_ Document Name
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Contracts

Invoiced items should align with this budget category and the narrative/ justification for requested funds in the Grant Application Budget Workbook, also identified in the Grant Agreement Exhibit C
Do you have Contracts expenses to submit on this invoice?*

YesNo
Estimated reimbursement for Contracts expense:*
Please attach Contracts supporting documentation, which should reasonably substantiate invoiced expenses:*

File Naming: Contracts_Document Name
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Services

Invoiced items should align with this budget category and the narrative/ justification for requested funds in the Grant Application Budget Workbook, also identified in the Grant Agreement Exhibit C
Do you have Services expenses to submit on this invoice?*

YesNo
Estimated reimbursement for Services expenses:*
Please attach Services supporting documentation, which should reasonably substantiate invoiced expenses:*

File Naming: Services_Document Name
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Other

Note: Only to be used if you were allocated funds for "Other" expenses not defined above, located in the approved Grant Application Budget Workbook, also identified in the Grant Agreement Exhibit C. Invoiced items should align with this budget category and the narrative/ justification for requested funds.
Do you have Other expenses to submit on this invoice?*

YesNo
Estimated Payment for Other Expenses*
Please attach Other supporting documentation which should reasonably substantiate invoiced expenses:*

File Naming: Other Budget Category_ Document Name
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Total Estimated Invoice Amount

The total estimated amount will equal the sum of direct costs and indirect costs invoiced this month. PCG will review the invoice submission for accuracy and contact your organization if there are any discrepancies that need to be resolved prior to payment.
Total Estimated Direct Costs
This will auto calculate the sum of Personnel, Fringe, Travel, Training, Equipment, Supplies, Contracts, Services and Other.
Hidden- Direct Amount
Total Indirect Costs
Indirect Costs must be aligned with 2CFR200 Requirements for indirect. Grantee should maintain records to substantiate indirect costs in the event of future monitoring and as required by the Terms and Conditions of this grant.

CFR 200 Information
Do you want to claim indirect costs on this invoice?*

YesNo
Do you have a federally approved indirect rate that is greater than 10%?*

YesNo
What is your approved indirect rate, as a decimal?*
Example if 18.5% enter .185
Upload proof of approved federal indirect rate*

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PCG will calculate the indirect cost during their invoice review based on available budget and indirect rate approved for your organization.
Total Estimated Indirect Costs:
This will auto calculate 10% of the Total Estimated Direct Costs
Total Estimated Indirect Costs >10%:
This will auto calculate the approved indirect rate of the Total Estimated Direct Costs
Total Estimated Amount of Payment from Invoice if ID 10%:
Total Estimated Amount of Payment from Invoice if ID>10%:
Total Estimated Amount of Payment from Invoice if no ID:
I certify, by signing below, that our organization has not already been paid by this grant or another CO ARPA grant for these deliverables/expenses and that all information is true,correct, accurately represents the work contracted to perform, and has been delivered in accordance with the grant requirements.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MFP Capacity Building Monthly Report and Invoice Form

Contact Information

Grantee Organization Information

Deliverables

Work Plan

Mid-Year Project Report

Final Report

Monthly Report

Expense Information for Payment

Personnel

Fringe Benefits

Travel

Training

Equipment

Supplies

Contracts

Services

Other

Total Estimated Invoice Amount

Total Indirect Costs