Financial Status Report Michigan Department Of Community Health

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FINANCIAL STATUS REPORT
MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
Contract Number
Page
Of
Local Agency Name
Program
Code
Street Address
Report Period
Date Prepared
Final
Thru
City, State, ZIP Code
Agreement Period
FE ID Number
Thru
Expenditures
Agreement
Category
Current Period
Agreement YTD
Budget
Balance
1. Salaries & Wages
2. Fringe Benefits
3. Travel
4. Supplies & Materials
5. Contractual
(Sub-Contracts)
6. Equipment
7. Other Expenses
8. TOTAL DIRECT
9a.Indirect Costs Rate #1:_%
9b.Indirect Costs Rate #2:_%
10. TOTAL EXPENDITURES
SOURCE OF FUNDS:
11. State Agreement
12. Local
13. Federal
14. Other
15. Fees & Collections
16. TOTAL FUNDING
CERTIFICATION: I certify that I am authorized to sign on behalf of the local agency and that this is an accurate statement of expenditures and collections for
the report period. Appropriate documentation is available and will be maintained for the required period to support costs and receipts reported.
Authorized Signature
Date
Title
Contact Person Name
Telephone Number
FOR STATE USE ONLY
Advance
INDEX
PCA
A OBJ. CODE
AMOUNT
Advance Outstanding
Advance Issued or Applied
Balance
Message
Authority: P.A. 368 of 1978
The Department of Community Health is an equal opportunity,
Completion: is a Condition of Reimbursement
employer, services, and programs provider.
DCH-0384(E) (Rev. 4/04) (W) Previous Edition Obsolete

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