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California's Opioid Bankruptcies
Expenditure Reporting Form
Local Governments receiving funds from opioid bankruptcies are required to complete annual reporting on the use of these funds. Currently, California has reached a final
Statewide Allocation Agreement
with
Mallinckrodt Pharmaceuticals. Funds from the Mallinckrodt Bankruptcy are distributed directly to Local Governments from the National Opioid Abatement Trust II Fund (NOAT II).
This form is intended to collect expenditure information from Local Governments receiving payments from NOAT II. A list of Local Governments can be found within California’s Mallinckrodt
Statewide Allocation
Agreement
. If you have questions about your Local Government's status, please reference this agreement, or contact your city, county, or outside counsel handling opioid related matters.
This reporting form covers the period of July 1, 2022 – June 30, 2023.
Please ensure all responses reflect the 2022 – 2023 State Fiscal Year (SFY).
The reporting period will run through
November 30, 2023.
For the SFY 2022-
2023 reporting period, DHCS will allow a one-time grace period for expenditure form submissions and will accept submissions until December
31, 2023.
If you have any questions filling out this form, please review the Q&A
If you have any questions filling out this form, please review the Q&A
document.
If you need to submit a revision to already submitted data, please contact the UCLA Evaluation team by emailing Diane Hilderbrand
at
[email protected].
Necessary Materials
To see a comprehensive list of necessary materials and information, please view the
Necessary Materials Checklist
. You will need the following
information to complete this form:
The amount of Mallinckrodt Bankruptcy funds received by your Local Government from the National Opioid Abatement Trust (NOAT) II in State Fiscal Year (SFY) 2022-2023;
The amount of Mallinckrodt Bankruptcy funds expended by your Local Government, by allowable use categories, in SFY 2022-2023; Reallocations to/from other Local Governments
Interest earned on Mallinckrodt Bankruptcy funds received by and/or reallocated to your Local Government in SFY 2022-2023; and The amount of Mallinckrodt Bankruptcy funds spent on administrative costs.
This form must be submitted online.
If you would like to see a copy of the
entire reporting form prior to completing it, please download the Mallinckrodt Bankruptcy Expenditure Reporting Form PDF.
Word Document
and PDF versions will not be accepted, they are for your reference only.
Submission Requirements
Local Governments shall only submit one (1) expenditure report annually for bankruptcy funds received from NOAT II.
Do not send this expenditure reporting form to contractors or sub- grantees to whom you may have awarded your bankruptcy funds.
Local
Governments are responsible for the oversight and disbursement of funds for opioid abatement. It is the Local Government’s responsibility to collect all required information regarding the funds they have received and expended and to compile it into a singular report.
The preparer of the Mallinckrodt
Bankruptcy
Expenditure Report should
be the only person to submit one (1) expenditure report for your Local Government.
1. General Information
This section will ask for general information about your Local Government and the person preparing the report.
Local Government:
(Select the correct Local Government you are reporting for. A list of Local Governments can be found within California’s Mallinckrodt Statewide
Allocation Agreement
.)
Local Government address:
(Please format as 0000 Street Name, City, State Initials Zip Code.) Name of preparer:
(Please include the first and last name of the individual preparing this form.) Job title or classification:
(Please indicate the job title or job classification of the individual preparing this form.)
Preparer email address:
(This email will receive confirmation of the report submitted. Please ensure that it is correct.)
Merced City
678 W. 18th St.,
Merced, CA
95340
M. Venus Rodriguez
Finance Officer
Confirm email address:
Preparer phone number:
(xxx-xxx-xxxx)
2. Payments
This section will cover bankruptcy funds received from NOAT II, interest earned, and reallocations to and from your Local Government.
1. Total amount of bankruptcy funds received from NOAT II from July 1, 2022 – June 30, 2023:
2. Total interest earned on bankruptcy funds received from NOAT II from July 1, 2022 – June 30, 2023:
Reallocations
To
Other Local Governments
In this section, please report funds that were received by your Local Government from NOAT II, and then transferred to a different Local Government.
If your city has opted out of receiving funds from the Mallinckrodt Bankruptcy and informed NOAT II of this election, you are not required to report.
[email protected]
[email protected]
209-385-8547
5489.82
0.00 3. Did you
reallocate
any of your bankruptcy funds received from NOAT II to
another Local Government?
Reallocations
Received
From Other Local Governments
In this section, please report funds that were transferred to you from a different Local Government, after they received them from NOAT II.
If your Local Government received funds from NOAT II that include funds deferred by another Local Governments, please do not report these funds separately. These funds are included in the total amount received by the Local Government and reported in the above payment section.
4. Did you
receive
any bankruptcy funds from another Local Government?
3. Expenditures
In this section, Local Governments will report their expenditures.
Did your Local Government expend any bankruptcy funds during the period of July 1, 2022 - June 30, 2023?
4. Administrative Expenses
Per Section 2 of the NOAT II Trust Distribution Procedures, qualifying expenditures may include reasonable related administrative expenses.
Yes
No
Yes
No
Yes
No
Please provide the amount of bankruptcy funds spent on administrative costs.
Administrative costs are defined as expenses incurred in administering the distributions for Approved Opioid Abatement Uses, including the process of selecting programs to receive distributions of bankruptcy funds for implementing those programs.
Per Section 2 of the NOAT II Trust Distribution Procedures, no more than five percent (5%) of the bankruptcy funds may be used to fund expenses incurred in administering the distribution for the Approved Opioid Abatement Uses. During the period of July 1, 2022 - June 30, 2023, did your Local Government expend more than five percent (5%) of the bankruptcy funds on administrative expenses?
I acknowledge on behalf of my Local Government that no more than five percent (5%) of the bankruptcy funds may be used to fund expenses incurred in administering the distributions for the Approved Opioid Abatement Uses.
5. Technical Assistance
0.00 Yes
No
×
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A
Does your Local Government want technical assistance on how to spend opioid bankruptcy funds?
6. Attestations
I certify and attest on behalf of my Local Government that all funds received have been used in compliance with the requirements of the California Mallinckrodt Statewide Allocation Agreement
and the
NOAT II
Trust Distribution Procedures
.
I certify and attest on behalf of my Local Government the information included in this report is provided by the Beneficiary identified above in accordance with requirements of the
California Mallinckrodt Statewide
Allocation Agreement
and the
NOAT II Trust Distribution Procedures
.
Yes
No
×
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clear
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