Periodic Financial Report and Periodic Performance Report templates

Helping Families. Supporting Communities. Empowering Individuals.

DMH Service Providers,

The Periodic Financial Report and Periodic Performance Report templates and their instructions are now available on the DHS/DMH Grants Billing and Reporting Webpage for your use in accordance with the uniform grant agreement Exhibits C and E.

  1. The Periodic Financial Report template (GOMBGATU-4002 (N-08-17)) as required by Exhibit C allows you to add or delete rows in section (x) Category/Program Expenses of the template by clicking on ADD or DEL in the far right column. This will enable you to capture all line items that are included in your approved budget.
  2. The Periodic Performance Report templates as required by Exhibit E consist of two separate templates, one general template (GOMBGATU-4001 (N-08-17)) as well as a specific template for each program identified by program number and name. Both forms are required. When completing the GOMBGATU template, you must complete items 1-13 and 23-26. You will see a note in red that states, "Responses to Sections 14 - 22 may be provided in a separate format." Check the box beside "Alternative file or database used." In the box labeled, "File Name or Database Source," state "DHS/DMH provided program template." DMH requires that you use the specific template identified by program number and name in lieu of Sections 14 - 22 for each grant agreement. The submission of the Periodic Performance Report should include both documents for each grant agreement.

All three templates for each grant agreement should be submitted to the program contact, and a link to the program contact list has been provided on the webpage. Please refer to your individual grant agreements, Exhibits C and E, for the required frequency of reporting for each grant agreement.

http://www.dhs.state.il.us/page.aspx?item=95429

You may navigate to the DHS/DMH Grants Billing and Reporting webpage as follows:

DHS Website: http://www.dhs.state.il.us

Click on: for Providers

Under Provider Information by Division click on: Mental Health Provider Information

Under Provider's Tools & software click on: Grants Billing and Reporting

Or follow the link below to go directly to the page.