Affidavit Of Expenditures
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2KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT
AFFIDAVIT OF EXPENDITURES
PART C OF IDEA INFANT TODDLER SERVICES
GRANTEE NAME/TITLE OF AWARD:
Person who can answer questions regarding this report:
PHONE:
REPORT PERIOD:
EXPENDITURE CLASSIFICATION
Total Salary
% Part C
Local
For Report
Time
Expenditure
SALARIES (Including fringe benefits)
Period
Worked for
Amount
List name & position of employee
Period
Sub-total Salaries
0.00
TRAVEL (provide brief detail)
Sub-total Travel
0.00
SUPPLIES (Itemize/provide brief detail)
Sub-total Supplies
0.00
CAPITAL EQUIPMENT (ITEMIZE)
(List each item, make, model, serial#; include copy of invoice)
Sub-total Capital Equipment
0.00
OTHER (ITEMIZE)
Sub-total Other
0.00
AFFIDAVIT TOTALS
0.00
The local agency administrator below certifies that this report is in agreement with the agency official accounting
records and that individual employee time reports are maintained documenting time charged to this program.
AUTHORIZED SIGNATURE:
Date:
SFY2016
KDHE USE ONLY: __________
Audited by:___________
*Attach additional sheet(s) as necessary
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