Docs for Contracts by zjj35309

VIEWS: 4 PAGES: 1

More Info
									 HARRIS COUNTY PUBLIC HEALTH & ENVIRONMENTAL SERVICES - RYAN WHITE GRANT ADMINISTRATION

CER                     CONTRACTOR EXPENSE REPORT
                                                                                       (For RW Grant Administation use) REV. 02/25/10


NAME OF CONTRACTOR:
SERVICE:                                            FUND: BEK27516
CONTRACT NO:                                       Contract Period: 3/1/10 - 2/28/11
Check box if FINAL (LAST) REPORT   o                                 Advance Amount:
REPORT PERIOD (month & year):                                        Advance Balance:
Reimbursement Amount (less advance repayment):                       Advance Repayment this Month:
REMIT PAYMENT TO:                              AGENCY IS RESPONSIBLE FOR ADDING MAILING ADDRESS HERE

                                                         FEE FOR SERVICE
                           A:         B:                   C:                D:               E:             F:             G:
      SERVICE         TRANSACTION UNITS THIS        DISBURSEMENTS ANNUAL BUDGET         COSTS THIS      CUMULATIVE       BALANCE
       TYPES            FEE/UNIT   PERIOD              (if applicable)                    PERIOD          COSTS            (D-F)
                                                                                         (A x B + C)       (YTD)




                                                      TOTALS:
                                                                                          Less Advance Balance
                                                         ACTUAL BALANCE AVAILABLE
            HRSA WICY DEMOGRAPHICS (Amount Expended should include unit fee + disbursements)

Infants (0-<2)        Total Amount Expended                            Youth (13-24) Total Amount Expended

Children (2-12)       Total Amount Expended                            Women (25+)     Total Amount Expended
                                                          CERTIFICATION
I certify that the above services were rendered, or goods delivered, and that they correspond in every respect with the
contract under which they were procured and that the supportive documentation is true and accurate.


Signature                                                                              Date
     BY SUBMITTING THIS FORM, AGENCY ACCEPTS FULL RESPONSIBILITY FOR FORMULAS
                        UTILIZED AND CALCULATIONS REPORTED.
    SUBCONTRACTOR MUST ATTACH SUPPORTING DOCUMENTATION FOR ALL EXPENDITURES REPORTED
FOR RYAN WHITE GRANT ADMINISTRATION USE ONLY:                                          ACR o           OUTCOMES o

INVOICE                                                                                PO#
                                                                                                       Batched:
Doc. Rev.                              Acct.                         Approval:
FOR AUDITOR'S OFFICE: Supporting documentation, including disbursements, has been reviewed by
the Public Health & Environmental Services Department and is available upon request.

                                       CER MAY NOT EXCEED ONE PAGE

								
To top