Expenditure Report Form

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EXPENDITURE REPORT
State of Wisconsin
Community Aids Reporting System
Department of Workforce Development
Income Maintenance Programs
Administrative Services Division
INSTRUCTIONS:
Agency Number
Agency Name
STATE USE ONLY
1. Report expenses in whole dollars.
Date Entered in CARS
Agency Type
Agency Contact
2. See Contract for current Agency
104
Number and Agency Type.
Operator Initials
Report Period (mm/yy)
Phone Number
/
FINAL REPORT
PROFILE
CURRENT NET
CONTRACT-TO-DATE
PROFILE NAME
COMMENTS
NUMBER
EXPENDITURES
NET EXPENDITURES
ALLOCATED EXPENDITURES
76
IM SUB-ALLOCATED
DIRECT CHARGED EXPENDITURES
123
W2-FUNERAL
124
W2-CEMETERY
126
NON-W2 FUNERAL/CEMETERY
131
MEDICAID TRANSPORTATION
221
REGIONAL TRAINING - FACILITIES
222
REGIONAL TRAINING - STAFF
291
MA SUBROGATION COLLECTION
292
AFDC/W2 SUBROGATION COLLECT
293
AFDC/W2 ESTATE COLLECTIONS
747
PROGRAM INTEGRITY – AMSO
748
PROGRAM INTEGRITY - ADMIN
749
PROGRAM INTEGRITY - PREVENT
845
CC – SAFE CHILD INITIATIVE
850
CHILD CARE ADMIN
851
CHILD CARE PROGRAM OPERATION
854
CHILD CARE BENEFIT-W2
855
CHILD CARE BENEFIT-FSET
909
MEDICAL REFUNDS
521037*
LOCALLY MATCHED CCDF
*ends 9/30/02
521039*
LOCALLY MATCHED CCDF ADMIN
*ends 9/30/02
521043*
LOCAL-MATCH ADMIN 10%
*ends 9/30/02
TOTAL REIMBURS. EXPENDITURES
I certify that the expense and revenue identified here claiming federal and state reimbursement pursuant to section 46.495 are true and correct in the
amounts stated, have not been reimbursed previously, and represent actual and necessary costs of administering provisions of the contract.
SIGNATURE -
Date Signed
Treasurer or Financial Manager
SIGNATURE -
Date Signed
Administrator
Send Original to: DWD/CARS Unit, P.O. Box 7946, Madison, WI 53707-7946
Retain One Copy for Agency Records
FIS-10665 - 1 (R. 07/2001), (Formerly DMS-600IM)

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