Free F-26110I - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-26110I (07/2008)

STATE OF WISCONSIN

CONDITIONAL RELEASE / SUPERVISED RELEASE PROGRAM INVOICE ­ INSTRUCTIONS
Costs identified below should be calculated to that portion of services provided by your agency related to Supervised Release program or Conditional Release programs. The form can be completed electronically, printed, signed and submitted to the appropriate Supervised Release program or Conditional Release program office. Communication Equipment Insurance / Liability Miscellaneous Costs Postage Rent / Occupancy Salaries / Benefits Sub-Contract Costs Supplies Support Services Salaries / Benefits Training / Professional Fees / Dues Travel Indirect Administrative Costs Service costs for telephone, cellular phone and pager costs Permanent items such as desks, chairs, computers, cell phones, fax machines, etc. purchased with DHS funds, which then become the property of DHS and not the provider. Malpractice and other relevant insurance Other costs related to services, which are beyond the scope of the above categories. This category shall not exceed $500 in any 12-month (one-year) period. Stamps and postal service costs. Cost of leasing office space. Costs for employment of staff Sub contract costs for the provision of statutorily mandated or court ordered services Consumable items such as paper, pens, file folders, etc. and services such as printing Clerical, receptionist, secretarial services. Costs related to maintaining professional certification, standards of practice and membership in professional organizations related to provision of services. Mileage and other travel costs. Costs related to management and supervision.