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					Annexure
Statement of Fund Position
(Format for Quarterly Reporting of Cash, Bank and Expenditure)
(State may call for similar reports from the District Health Society)

Name of the State/UT: …………………………..

Statement for the Fund Position for the quarter ending: ……………………

Sl. No     Scheme          Opening Balance at the beginning of the       Fund    *Actual Refund to
                                       quarter (Rs.)                    ReceivedExpenses   GOI
                                                                     during the Incurred
                                                                      quarter during the
                                                                        (Rs)     quarter
                                                                                   (Rs)
                           Bank     Advances Cash         Total                   (To be   (Rs.)
                                    (including                                    tallied
                                    Releases to                                    with
                                    District &                                    FMR)
                                       other
                         Balance     agencies) Balance
A          RCH
           Flexible
           Pool (Part
           A of PIP)
B          Additional
           ties under
           NRHM
           (Part B of
           PIP)
           (This will
           include all
           sanctions/r
           eleases
           made
           during
           2005-06 &
           2006-07
           under
           Additionalt
           ies under
           NRHM)
C          Immunizat
           ion (Part
           C of PIP)
C.1 & C.2 RI
          Strengtheni
          ng Project
          (Including
          Cold Chain
          Maintenanc
          e)


C.3         Pulse Polio
            Operating
            Costs

                Total
            Immunisat
                  ion
D           RCH–    I
            (Provide
            separate
            detail    for
            each
            activity)
E           Interest
            Earned
            TOTAL           B1       A1           C1           T1

* Actual expenditure includes expenditure incurred by State Health Society itself and District health societies. (To be tallied with FM
Source documents, which must be verified before showing figures under each category, are: Cash Book, Bank Book and Advance Register

It is certified that:
1. Opening and Closing figures of Bank Balance tally with the Bank Book of the Society (State may call for similar report from the districts
2. Opening and Closing figures of Advances tally with the Advance Register of the Society,
3. Opening and Closing figures of Cash tally with the Cash Book of the Society.
4. That expenditure shown in the quarter tally with the expenditure reported in the Financial Monitoring Report (FMR) for the quarter.


Prepared and Checked by:
State Accounts Manager and / or
State Finance Manager
 Unspent Balance at the end of the quarter
                  (Rs)




Bank       Advances Cash         Total
           (including
           Releases to
           District &
              other
 Balance    agencies) Balance
                B2           A2            C2    T2

 health societies. (To be tallied with FMR)
Book, Bank Book and Advance Register (Ledger).


y call for similar report from the districts),


ring Report (FMR) for the quarter.




                                                      Signature of the Mission Director
Annexure
Statement of Fund Position
(Format for Quarterly Reporting of Cash, Bank and Expenditure)
(State may call for similar reports from the District Health Society)

Name of the State/UT: …………………………..

Statement for the Fund Position for the quarter ending: ……………………

Sl. No   Scheme                                                    Opening Balance at the beginning of the     Fund
                                                                               quarter (Rs.)                  Received
                                                                                                             during the
                                                                                                              quarter
                                                                                                                (Rs)

                                                                Bank        Advances Cash         Total
                                                              Balance       (including Balance
                                                                            Releases to
                                                                            District &
                                                                               other
                                                                             agencies)

A        RCH Flexible Pool (Part A of PIP)

B.1      Selection and training of ASHA
B.2      Untied Fund for Sub-Centres
B.3      Upgradation of CHC to IPHS
B.4      District Action Plan
B.5      Corpus Grant to HMS/RKS
B.6      Procurement of ASHA Drugs Kits
B.7      Mobile Medical Units
B.8      Any Other Heads as specified by GOI
B        Additionalties under NRHM (Part B of PIP)

C.1      RI Strengthening Project
C.2      Cold Chain Maintenance
C.3      Pulse Polio Operating Costs
C        Immunization (Part C of PIP)
C.1 &    RI Strengthening Project (Including Cold
C.2      Chain Maintenance)

C.3      Pulse Polio Operating Costs
                                      Total Immunisation

D        RCH– I (Provide separate detail for each activity)

E        Interest Earned
         TOTAL                                                B1           A1             C1      T1

* Actual expenditure includes expenditure incurred by State Health Society itself and District health societies. (To be tallied with FM
Source documents, which must be verified before showing figures under each category, are: Cash Book, Bank Book and Advance Register
It is certified that:
1. Opening and Closing figures of Bank Balance tally with the Bank Book of the Society (State may call for similar report from the districts
2. Opening and Closing figures of Advances tally with the Advance Register of the Society,
3. Opening and Closing figures of Cash tally with the Cash Book of the Society.
4. That expenditure shown in the quarter tally with the expenditure reported in the Financial Monitoring Report (FMR) for the quarter.


Prepared and Checked by:
State Accounts Manager and / or
State Finance Manager
                *Actual Refunds to Unspent Balance at the end of the quarter
              Expenses     GOI                        (Rs)
               Incurred
              during the
                quarter
                 (Rs)
                          (Rs.)   Bank      Advances Cash           Total
                                   Balance  (including Balance
                                               Releases to
                                               District &
                                                  other
                                                agencies)




                                     B2       A2             C2     T2

 societies. (To be tallied with FMR)
Bank Book and Advance Register (Ledger).
or similar report from the districts),


 port (FMR) for the quarter.




                                         Signature of the Mission Director
ture of the Mission Director
Annexure
Statement of Fund Position
(Format for Quarterly Reporting of Cash, Bank and Expenditure)


Name of the District Health Society : …………………………..

Statement for the Fund Position for the quarter ending: ……………………

Sl. No Scheme                                                   Opening Balance at the beginning of the quarter (Rs.)            Fund           *Actual      Refunds          Unspent Balance at the end of the quarter (Rs)
                                                                                                                                Received       Expenses
                                                                                                                               during the      Incurred
                                                                                                                              quarter (Rs)    during the
                                                                                                                                             quarter (Rs)

                                                                 Bank          Advances      Cash             Total                                            (Rs.)     Bank          Advances Cash            Total
                                                             Balance            including    Balance                                                                      Balance      (including Balance
                                                                               Releases to                                                                                             Releases to
                                                                                  other                                                                                                District &
                                                                                agencies)                                                                                                 other
     1 Block 1                                                                                                                                                                          agencies)


     2 Block 2
     3 Block 3
     4 Block 4
     5 Block 5
     6 Block 6

     7 Block 7

     8 Block 8




        TOTAL                                                B1              A1              C1               T1                                                         B2           A2            C2          T2

* Actual expenditure includes expenditure incurred by District health societies. (To be tallied with SOE's)
Source documents, which must be verified before showing figures under each category, are: Cash Book, Bank Book and Advance Register (Ledger).

It is certified that:
1. Opening and Closing figures of Bank Balance tally with the Bank Book of the Society (State may call for similar report from the districts),
2. Opening and Closing figures of Advances tally with the Advance Register of the Society,
3. Opening and Closing figures of Cash tally with the Cash Book of the Society.
4. That expenditure shown in the quarter tally with the expenditure reported in the SOE's for the quarter.

Prepared and Checked by:                                                                                                                         Signature of the Chief Medical Officer
District Accounts Manager

				
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posted:10/7/2011
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