New York State Office of Mental Health
Document Requirements for New OMH Local Assistance Contracts
with Amendment Number "0"

(e.g. Contract C00XXXX/0 from the Contract Summary Report by Contract)

Item Non-Residential
Funds		 Residential
Funds		 Shelter Plus Care Funds Legislative Special Projects

Contract Face Pages 1 & 2

X X X X
Contract Signature Page X X X X
Master Contract for Grants/Standard Terms and Conditions X X X X
Attachment  A-1 (OMH Specific Clauses) X X X X
Attachment A-1(a) MWBE and EEO Requirements X X X X
Exhibit 1 - MWBE Utilization Plan X9 X9 X9 X9
Exhibit 2 - MWBE Request for Waiver X9 X9 X9 X9
Exhibit 2a - Certification of Good Faith Efforts X9 X9 X9 X9
Exhibit 3 - Contractor Quarterly Compliance Report X9 X9 X9 X9
Exhibit 4 - EEO Workforce Utilization Report X9 X9 X9 X9
Attachment A-2 (Federally Funded Grants) X1 X1 X1  
Attachment A-2(a) Shelter Plus Care Regulations     X  
Attachment B-4 (Net Deficit Budget) X2 X2 X2 X2
Attachment C (Work Plan) X X X X
Attachment D (Payment and Reporting Schedule) X X X X
Attachment E (Certification of Licensed Programs - to be completed by OMH) X3 X3    
Attachment F (Business Associate Agreement) X X X X
Non-Licensed Program Rider X8 X8 X8
Residential Program Rider   X    
HCBS Waiver Program Rider X4      
Assisted Outpatient Treatment Rider X5 X5    
Community Projects Rider       X7
Certification Appendix (Disclosure & Accountability Certification) (Less than or equal to $50,000) OR;       X7
Certification Appendix (Disclosure & Accountability Certification) (Greater than $50,000)       X7
Vendor Responsibility Questionnaire X X X X
Proof of NYS Workers’ Compensation  (or exemption) X X X X
Proof of NYS Disability Benefits Insurance (or exemption) X X X X
NY Charities Registration (or exemption) X X X X
Federal Certification Form 1 X6   X6  
Federal Certification Form 2 X6   X6  

1 Required if Federal funds are included in contract.
2 Budget is submitted electronically through Consolidated Fiscal Reporting System (CFRS); do not submit paper copy.
3 Required if contract includes licensed programs. Only for Multi-year Contracts. Not required for Fixed Term Contracts.
4 Required for contracts with OMH Children’s HCBS Waiver Programs only.
5 For outpatient treatment programs involving court ordered population only.
6 Original signed Federal certification forms are required if Federal funds are included in the contract.
7 Required for 007 funded member items only.
8 Required if contract includes non-licensed programs. Not required for fixed-term contracts.
9 Required if MWBE Goals are assigned. Goals are identified on the attachment A-1(a) MWBE & EEO Requirements

February 2021