Form Soc 432 - Claim For Reimbursement - In-Home Supportive Services Program - Contract Expenditures Page 2

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SECTION I
OVERPAYMENTS/UNDERPAYMENTS
PCSP CASES IPW CASES
IHSS CASES PCSP HOURS IPW HOURS IHSS HOURS PCSP GROSS IPW GROSS IHSS GROSS
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
A
PAYMENT
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
CONNECTED
B
PAYMENT
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
ADJUSTMENT
C
+ / =
SECTION II
OTHER ______________________________ (COUNTY SPECIFIC)
PCSP CASES IPW CASES
IHSS CASES PCSP HOURS IPW HOURS IHSS HOURS PCSP GROSS IPW GROSS IHSS GROSS
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
D
BILLED
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
ADJUSTMENT
E
+ / =
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
F
NET BILLED
SECTION III
LIQUIDATED DAMAGES
PCSP CASES IPW CASES
IHSS CASES PCSP HOURS IPW HOURS IHSS HOURS PCSP GROSS IPW GROSS IHSS GROSS
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
G
BILLED
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
ADJUSTMENT
H
+ / =
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
I
NET BILLED
SECTION IV
PCSP / IHSS ADJUSTMENTS
PCSP CASES IPW CASES
IHSS CASES PCSP HOURS IPW HOURS IHSS HOURS PCSP GROSS IPW GROSS IHSS GROSS
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
NET
J
ADJUSTMENT
C + E + H (+ / =)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
ADJUSTMENT
K
+ / =
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
TOTAL NET
L
ADJUSTMENT
+ / =
SECTION V
CONTRACTOR BILLING
SERVICE
MONTH
(1)
PCSP CASES IPW CASES
IHSS CASES PCSP HOURS IPW HOURS IHSS HOURS PCSP GROSS IPW GROSS IHSS GROSS
M
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
INVOICE
N
BILLED
NET
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
ADJUSTMENT
O
+ / =
C + E + H or L
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
TOTAL NET
P
ADJUSTMENT
+ / =
SOC 432 (8/04)
PAGE 2 OF 2

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