Rebuilt from a real filed form with every client name, amount, and identifying detail removed. Columns, categories, and formulas are preserved exactly as the funder issues them.
Who files this
DOHMH-contracted providers submitting ledger backup with their invoices.
Key requirements
Funder
NYC Department of Health and Mental Hygiene
Jurisdiction
New York City
Fringe range
8.25%–35%
Indirect cost basis
Accepted ICR under the NYC HHS Cost Manual — 15% de minimis default if no NICRA or CPA-verified rate is on file
What gets this form kicked back
The ledger has to show contract-charged transactions only — a full-organization ledger dump invites questions about costs that were never charged to DOHMH.
Vendor names and transaction dates need to match the invoices in your files; DOHMH samples these.
Allowable OTPS categories
The categories NYC DOHMH recognizes on a budget or voucher. Using wording outside this list is a routine cause of returned submissions.
Clinical Consultation
Staff Training & Certification
Program Consultants
Supplies — Office
Supplies — Program / Health
Supplies — Medical / Clinical
Travel — Staff
Transportation — Clients
Equipment
Equipment Maintenance
Printing / Health Materials
Training
Licenses & Permits
Unallowable costs
Costs NYC DOHMH will not reimburse under this contract.
Non-clinical supplies
Rules worth knowing before you file
HIPAA may apply for clinical and behavioral-health programs handling PHI — not a blanket requirement for every DOHMH contract
Three written estimates required over $25,000, or over $3,500 for federally-funded subrecipients
Petty cash capped at $1,500, with no per-expense sub-limit specified
Free voucher checker: upload a completed copy of this form and it flags unallowable costs, fringe above the ceiling, allocations that don't total 100% and totals that don't reconcile before you file. No signup; the file never leaves your browser.
Why vouchers get returned: the six checks behind most returned vouchers, and what each one looks like in a real file.
Stop filling this in by hand
Prove It Financials generates this exact form every month, populated from your own budget, payroll and invoices — with allocation percentages, fringe, and indirect already calculated and validated against NYC DOHMH's own rules.