Imprest Cash Voucher by steepslope9876

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									                                                                    Kentucky Cabinet for Human Resources                                                    TO BE COMPLETED WHEN PAYMENT IS MADE
DSS-110       Vendor No.                                                 Department for Social Services
(Rev. 7-88)
                                                                            RECEIVING REPORT                                                                 Account No.
                                                                          IMPREST CASH VOUCHER
Doc. No.      County No.                                                                                                                                     Check No.
                                        Vendor Name                                                                                                          Amount Paid
                Method of
                Payment                 Address                                                                                                              Date Paid
                   1. Regular Pay       City                                                                  State                Zip                       Authorization
                   2. Trust Fund          Contract Number                                                                                                    Number

TYPE OF PROGRAM                                1. Adoptions                               2. Foster Family Care                           3. Private Institutions and Boarding School Care
                                               4. Family Treatment Home                   6. Unmarried Parent Program                     7. Other

       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  01                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  02                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  03                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  04                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  05                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  06                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  07                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  08                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  09                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


       Case Number          Child's Last Name                       Child's First Name               Child's SSN          Child's Birth      Type           Mo/YR            Quant.     Unit Cost       Total Cost
                                                                                                                          Date               Fo. Care       Service          or Days
  10                                                                                                                                                                                                            $0.00
       Financial      Commodity        Physical Description                County                Status     Pre-          Family Vendor                     Vendor Invoice Number          Invoice Date Entry/Exit
       Resource       Code                                                 of Origin             Code       Adoptive                                                                                    Date


I hereby certify that the commodities and boarding home care specified above have been furnished to the child by me, and that payment in whole
or in part has not been received.
                                                                                                                                                                                        Sub Total           $0.00
Provider Signature:                                                                                                                                                                     Total               $0.00
I certify that the items described hereon were received and inspected by me, that the quantities were as stated, and that the condition was satisfactory.

Worker or Authorized Person                                                                                  Date                                             Phone

Team Leader or Authorized Person                                                                                        Date                                          Page         of

								
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