DS-4213 Reporting Form.xlsx

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Overview

Instructions
Subrecipient Organization
Primes or Subs Over $25k
Subrecipients Under $25k

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Sheet 1: Instructions

DS-4213 President's Emergency Plan for AIDS Relief (PEPFAR) Program Expenditures
OMB Control No. 1405-0208 OMB approval expires 07/31/2024 Burden-24 hours

This template should be used for reporting Fiscal Year 2023 (October 1, 2022 - September 30, 2023) PEPFAR program expenditures by Implementing Partners and their subrecipients; a separate template should be completed for each separate Operating Unit (OU) and Award, and any subrecipients whose expenditures are greater than $25,000.

Please read through expenditure reporting guidance, instructions on this template prior to completing this form. All guidance and instructions can be found at https://datim.zendesk.com.

Public reporting burden for this collection of information is estimated to average 24 hours per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: Bureau of Global Health Security and Diplomacy (S/GHSD) U.S. Department of State, 1800 G Street, NW, 10th Floor, Washington, DC 20006.

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Sheet 2: Subrecipient Organization

Subrecipient Organization Name:
Subrecipient UEI:

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Sheet 3: Primes or Subs Over $25k

Prime Reporting or Subrecipient Reporting Over $25,000	Program Management	Categorization of Intervention 2	Categorization of Intervention 3	Categorization of Intervention 4	Categorization of Intervention 5	Categorization of Intervention 6	Categorization of Intervention 7	Categorization of Intervention 8	Categorization of Intervention 9	Categorization of Intervention 10	Categorization of Intervention 11	Categorization of Intervention 12	Categorization of Intervention 13	Categorization of Intervention 14	Categorization of Intervention 15	Categorization of Intervention 16	Categorization of Intervention 17	Categorization of Intervention 18	Categorization of Intervention 19	Categorization of Intervention 20	Categorization of Intervention 21	Categorization of Intervention 22	Categorization of Intervention 23	Categorization of Intervention 24	Categorization of Intervention 25	Categorization of Intervention 26	Categorization of Intervention 27	Categorization of Intervention 28	Categorization of Intervention 29	Categorization of Intervention 30	Categorization of Intervention 31	Categorization of Intervention 32	Categorization of Intervention 33	Categorization of Intervention 34	Categorization of Intervention 35
Intervention Name:
Program Area:
Beneficiary:
Cost Category	Program management expenditures	Expenditures against Intervention 2	Expenditures against Intervention 3	Expenditures against Intervention 4	Expenditures against Intervention 5	Expenditures against Intervention 6	Expenditures against Intervention 7	Expenditures against Intervention 8	Expenditures against Intervention 9	Expenditures against Intervention 10	Expenditures against Intervention 11	Expenditures against Intervention 12	Expenditures against Intervention 13	Expenditures against Intervention 14	Expenditures against Intervention 15	Expenditures against Intervention 16	Expenditures against Intervention 17	Expenditures against Intervention 18	Expenditures against Intervention 19	Expenditures against Intervention 20	Expenditures against Intervention 21	Expenditures against Intervention 22	Expenditures against Intervention 23	Expenditures against Intervention 24	Expenditures against Intervention 25	Expenditures against Intervention 26	Expenditures against Intervention 27	Expenditures against Intervention 28	Expenditures against Intervention 29	Expenditures against Intervention 30	Expenditures against Intervention 31	Expenditures against Intervention 32	Expenditures against Intervention 33	Expenditures against Intervention 34	Expenditures against Intervention 35	TOTAL	% TOTAL
Personnel: Salaries- Health Care Workers- Clinical																																				$0	0%
Personnel: Salaries- Health Care Workers- Ancillary																																				$0	0%
Personnel: Salaries- Other Staff																																				$0	0%
Fringe Benefits																																				$0	0%
Travel: International Travel																																				$0	0%
Travel: Domestic Travel																																				$0	0%
Equipment: Health Equipment																																				$0	0%
Equipment: Non-Health Equipment																																				$0	0%
Supplies: Pharmaceutical																																				$0	0%
Supplies: Health- Non Pharmaceutical																																				$0	0%
Supplies: Other Supplies																																				$0	0%
Contractual: Contracted Health Care Workers- Clinical																																				$0	0%
Contractual: Contracted Health Care Workers- Ancillary																																				$0	0%
Contractual: Contracted Interventions																																				$0	0%
Contractual: Other Contracts																																				$0	0%
Construction																																				$0	0%
Training																																				$0	0%
Other: Financial Support for Beneficiaries																																				$0	0%
Other: Other																																				$0	0%
Indirect Charges																																				$0	0%
Total Expenditure per Intervention (Sum of Cost Categories)	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	0%
Choose ONLY ONE Reporting Tab
Primes or Subs Over $25k Tab	Use this tab if your organization had total expenditures OVER $25,000
Subrecipients Under $25k Tab	Use this tab if you are a subrecipient AND your organization had total expenditures UNDER $25,000

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Sheet 4: Subrecipients Under $25k

Subrecipient Reporting Under $25k

Program Management

Categorization of Intervention 2

Categorization of Intervention 3

Categorization of Intervention 4

Categorization of Intervention 5

Categorization of Intervention 6

Categorization of Intervention 7

Categorization of Intervention 8

Categorization of Intervention 9

Categorization of Intervention 10

Categorization of Intervention 11

Categorization of Intervention 12

Categorization of Intervention 13

Categorization of Intervention 14

Categorization of Intervention 15

Categorization of Intervention 16

Categorization of Intervention 17

Categorization of Intervention 18

Categorization of Intervention 19

Categorization of Intervention 20

Categorization of Intervention 21

Categorization of Intervention 22

Categorization of Intervention 23

Categorization of Intervention 24

Categorization of Intervention 25

Categorization of Intervention 26

Categorization of Intervention 27

Categorization of Intervention 28

Categorization of Intervention 29

Categorization of Intervention 30

Categorization of Intervention 31

Categorization of Intervention 32

Categorization of Intervention 33

Categorization of Intervention 34

Categorization of Intervention 35

Intervention Name:

Program Area:

Beneficiary:

TOTAL

Expenditure:

$0

Choose ONLY ONE Reporting Tab

Primes or Subs Over $25 Tab

Use this tab if your organization had total expenditures OVER $25,000

Subrecipients Under $25k Tab

Use this tab if you are a subrecipient AND your organization had total expenditures UNDER $25,000