DANE COUNTY DEPARTMENT OF HUMAN SERVICES PROVIDER AGENCY EXPENSE REPORT THROUGH:
Provider Name: Contract #: *Provider Certified By:
Program Name: Program Group #: Date
1 2 3 4 5 6
Approved YTD YTD YTD YTD YTD
County-Funded County-Funded County-Funded County-Funded Expense County-Funded % Variance
Budget Admin Expense Program Expense Total ( = Col. 2 + 3) Budget from Budget
Subtotal A 0 0 0 0 0 #DIV/0!
Professional Fees 0
Data Processing Fees 0
Postage, Office, and Program Supplies 0
Food/Household Supplies 0
Auto Allowance 0
Vehicle Costs 0
Subtotal B 0 0 0 0 0 #DIV/0!
Mortgage Interest, Depreciation, 0
Property Taxes 0
Subtotal C 0 0 0 0 0 #DIV/0!
Assistance to Individuals 0
Subtotal D 0 0 0 0 0 #DIV/0!
Subtotal E 0 0 0 0 0 #DIV/0!
This section for Adult - DD only.
F. OFF-SETTING REVENUE
Show as negative numbers:
Government Benefits (SSI, SSDI, etc.) 0
Private Pay (Trust Funds, etc.) 0
Cost Share 0
Subtotal F 0 0 0 0 0 #DIV/0!
TOTAL A THROUGH F 0 0 0 0 0 #DIV/0!
*CERTIFICATION: I certify the expenses listed above are true, correct, and allowable, in the amount stated and have not been reimbursed heretofore.
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DANE COUNTY DEPARTMENT OF HUMAN SERVICES
EXPENSE REPORTS MUST BE PRESENTED USING THE ATTACHED FORMAT
Expense Report Instructions
Name Enter legal name per current Dane County Contract Agreement.
Name Enter name of the program identified in your current Dane County Contract Agreement.
Contract # Enter the current contract number.
Program Enter the current Program Group number provided by Dane County staff. It can be found on the
Group # Program Summary Form of the contract.
Column 1 Approved County-Funded Budget. Use amounts from the County-funded column of the
approved (i.e., signed by both parties to the contract) program budget.
Column 2 Year-to-Date County-Funded Admin Expense. Using the County’s definition of Admin, report
year-to-date County-funded Admin expenses in this column.
Column 3 Year-to-Date County-Funded Program Expense. Using the County’s definition of Program,
report year-to-date County-funded Program expenses in this column.
Column 4 Year-to-Date County-Funded Expense Total. This column is the sum of the expenses reported
in columns 2 and 3.
Column 5 Year-to-Date County-Funded Budget. Assuming this is a 12-month program, divide column 1 by
12; then, multiply the result by the number of months that have elapsed in the contract period. For
example: If this is the expense report for May, the YTD budget column is determined by dividing
column 1 by 12 and multiplying by 5.
Column 6 Year-to-Date % Variance from Budget. For each of the account categories (Personnel,
Operating, Space, Special Costs, Other, Off-setting Revenue), compute the percentage that year-to-
date expenses (Column 4) vary from the year-to-date budget (Column 5). Use one of the two
methods described below to find the percent. (Please round to two decimal places.) The Excel
Spreadsheet has this formula built in.
A. Subtract year-to-date total expenses (Column 4) from year-to date budget (Column 5).
B. Divide this difference by the year-to-date budget (Column 5).
C. Multiply the result of Step B by 100 to give the percent variance from budget.
A. Divide the year-to-date total expense (Column 4) by the year-to-date budget (Column 5).
B. Multiply the result by 100.
C. Subtract this result from 100. This is the percent variance from budget.
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