[Form 11 Header]
FROM: Department of Public Social Services
title
SUBJECT: Test item
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RECOMMENDED MOTION: That the Board of Supervisors:
First action recommended to the Supervisors. Motions are the only binding actions on the form 11. They should be clear, legally defensible, and accomplish what needs to be done to complete the action you are recommending to the Board.
Additional, as needed.
ACTIONS:
Consent
4/5 Vote Required
A-30
Change Order
Position Added
Policy
H-11
CIP
Set for Hearing
Information
Set for Meeting
5/9 Vote Required
Separate Vote Required
Table 1: FINANCIAL DATA
COST DATA
Current
Fiscal
Year
Next
Fiscal
Year
Total
Cost
Ongoing
Cost
COST
$ partial year
$ full year
$ (e.g. contract total)
$ (e.g. Operations)
NET COUNTY COST
$ partial year
$ full year
$ In dollars, no cents
$ In dollars, no cents
Table 2: SOURCE OF FUNDS
FUND NAME OR NUMBER
Budget Adjustment
For Fiscal Year
Give fund name or number. If external, give source (e.g. state grant, contract revenue). If multiple, give percent of each.
Yes or No
YYYY/YYYY
CHIEF EXECUTIVE OFFICER (CEO) RECOMMENDATION: [CEO use]
BACKGROUND:
Summary
Briefly summarizes the recommended action. The summary should include the critical information needed for the Board members to make an informed decision about whether or not to support the action.
Impact on Residents and Businesses
Explain briefly the expected impact on private residents or private businesses. Use general terms and very rough estimates. Rely on department expertise. Do not use intensive research or consultants.
Additional Fiscal Information
Summarize the full cost of the item before the Board. Describe the source(s) of funding. Include an explanation of new/ongoing costs not explicitly in the Form 11 (i.e., the operations cost of a new building).
Clearly show the cost per year for all years to be approved. For example, a 5-year contract should show the cost of each of the ...
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