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Monthly Expenditure Report - Baby Watch Early Intervention Program

VIEWS: 6 PAGES: 3

									                                                  Utah Department of Health
                                             Baby Watch Early Intervention Program

                                              MONTHLY EXPENDITURE REPORT

                                                                                                Month Reporting:                     July-2011
GRANTEE:                                Provider Name                                           Grant Number:                        00-0000

                                                                             EXPENSES

   I. Personnel Total *                               $                  -         III. Out-of-state Travel (Codes 6052-6057)           $                   -


     A. Wages & Salaries:                                  $             -         IV. Current Expense (Codes 6122-6287)                $                   -
                                                               (Code 5147)

     B. Benefits:                                          $             -              t Contractual Related Services (6135)*               $              -
                                                               (Code 5148)

     C. Incentive Awards                                   $             -              t Technical Services (6137)*                         $              -
                                                               (Code 5150)                                                                       (Code 6137)
     Contractual Related Services and Technical
     Services are listed under current expense.                                    V. Capital Outlay (Codes 6702-6705)
                                                                                       Prior approval is required for capital
  II. In-state Travel                                 $                  -             purchases.                                       $                   -

     A. Staff (Codes 6002-6006)                                        0.00        VI. Other Expenditures (Codes 7001-7002)
                                                                                       Child Find/Public Awareness Activities, LEA
     B. Parent (Codes 6008-6011)                                       0.00            Payments, Etc.                                   $                   -

                                           Total Monthly Expenditures $                            -
   * Please list the name, position, FTE or # hours, hourly rate, and monthly amount of all personnel, contractual related and technical services to
     be paid under this contract on Page 2 of 3 of the Monthly Expenditure Report.


                                                                             REVENUE

VII. Revenue

     A.      Medicaid Collections (8001)                   $             -             D.       Parent Fee Collections (8004)                $              -

     B.      LEA Payments (8002)                           $             -             E.       Other Collections (8005)                     $              -

     C.      CHIP Collections (8003)                       $             -                      Please Describe:


                                                  Total Revenue                $                   -




                                      Total Expenditures                       $                   -

                                      Less Total Revenue Received              $                   -

                                          Total Reimbursement                  $                   -




                                                                                                                                                     Page 1 of 3
                                                                                                                                                  Rev. 7/1/2008
                                                                                                                                              SSC\BWEIP Forms
                                                                                                                                      Monthly Expenditure Report
                                            Utah Department of Health
                                          Baby Watch Early Intervention
                                           Personnel Detail Information


MONTHLY EXPENDITURE DETAIL                                                           Month Reporting:             July-2010
Provider Name                                                                                     Grant #           00-0000
I. Salary/Wages:
                                                           FTE or                Monthly Salary/Wage (Code    Monthly Benefits (code
                   Name                   Position/Title           Hourly Rate
                                                           # hours                         5147)                     5148)




Personnel Totals:                                                                                      0.00                       0.00
Incentive Awards Total (specify):

6135 Contractual Related Services




6135 Contractual Related Services Total                                                                0.00

6137 Technical Services




6137 Technical Services Total                                                                          0.00




                                                                                                                             Page 2 of 3
                                                                                                                          Rev. 7/1/2008
                                                                                                                      SSC\BWEIP Forms
                                                                                                              Monthly Expenditure Report
                                                                  Utah Department of Health
                                                                 Baby Watch Early Intervention

MONTHLY EXPENDITURE REPORT                                                                                Month Reporting:                     July-2010
Provider Name                                                                                             Contract Number:                      00-0000

II. In-state Travel                                                               IV. Current Expense (Continued)
    A. Staff (Trips over $1,500/person, excluding registration,
    requires prior approval)                                                     Object Code/Description                                       Amount
Object Code/Description                                               Amount       6187      Small Equipment                                        0.00
  6002    In-state Auto Mileage Reimbursement                             0.00     6188      Office Furnishings                                     0.00
  6003    In-state Transportation                                         0.00     6194      Utilities                                              0.00
  6005    In-state Meal/Lodging Reimbursement                             0.00     6219      Related Services Supplies & Equipment                  0.00
          Total Staff In-State Travel                                     0.00     6221      Printed Forms and Publications                         0.00
    B. Parent                                                                      6263      Insurance and Bonds                                    0.00
  6008    In-state Auto Mileage Reimbursement                             0.00     6269      Training, Development and Registration                 0.00
  6009    In-state Transportation                                         0.00     6271      Special Events                                         0.00
  6010    In-state Meal/Lodging Reimbursement                             0.00     6274      Membership Dues                                        0.00
          Total Parent In-State Travel                                    0.00     6287      Unclassifed Other                                      0.00
                                                                                   6475      Computer Equipment                                     0.00
III. Out-of-state Travel (Staff and Parents) (Prior approval                                 Total Current Expense                                  0.00
    is required for all out-of-state travel over $1,500 per person,
    excluding registration)                                                        V. Capital Outlay - Prior written approval is required for capital
  6055    Out-state Meal/Lodging Reimbursement                            0.00        purchases over $5,000.00.
  6057    Out-state Transportation Reimbursement                          0.00     6702      Computer Equipment                                          0.00
          Total Out-of-state Travel                                       0.00     6703      Office Equipment                                            0.00
                                                                                   6704      Furniture                                                   0.00
IV. Current Expense                                                                6705      Program Equipment                                           0.00
  6122    Food for Clients                                                0.00               Total Capital Outlay                                        0.00
  6131    Advertising & Legal                                             0.00
  6132    Communication Services                                          0.00    VI. Other Expenditures
  6135    Contractual Related Services                                    0.00     7001      Child Find and Public Awareness Activities                  0.00
  6136    Postage & Mailing                                               0.00     7002      Payments to Local Education Agency (LEA)                    0.00
  6137    Technical Services                                              0.00               Total Other Expenditures                                    0.00
  6141    Indirect/Administrative                                         0.00
  6148    Payroll Processing                                              0.00   VII. Revenue
  6161    Rental-Land & Building                                          0.00               Medicaid Collections                                        0.00
  6162    Equipment Rental                                                0.00               Medicaid Payment Amount
  6163    Maintenance & Repairs                                           0.00               Medicaid Payment Amount
  6171    Buildings & Grounds                                             0.00               Medicaid Payment Amount
  6181    Office Supplies                                                 0.00     8002      LEA Payments
  6182    Printing and Binding                                            0.00     8003      CHIP Collections
  6184    Educational & Recreational Supplies                             0.00     8004      Parent Fee Collections
  6185    Books & Subscriptions                                           0.00     8005      Other Collections
  6186    Photocopy Expenses                                              0.00   Describe:
          Subtotal Current Expense                                        0.00               Total Monthly Revenue                                       0.00


  COMMENTS:




                                                                                                                                               Page 3 of 3
                                                                                                                                            Rev. 7/1/2008
                                                                                                                                        SSC\BWEIP Forms
                                                                                                                                Monthly Expenditure Report

								
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