DEPARTMENT OF HEALTH SERVICES Division of Public Health F-47257 (Rev. 01/09)
STATE OF WISCONSIN Bureau Of Local Public Health Practice and Emergency Medical Services s.256.12(4), Wis. Stats. (608) 266-0471
PROGRAM EXPENDITURE REPORT - EMS FUNDING ASSISTANCE FOR AMBULANCE SERVICE PROVIDERS
(Instructions on Page 2)
Completion of this form is required under section 256.12(4), Wis. Stats. The statute requires this financial report of expenditures as a condition of relicensure. Statutory language under section 256.12(4) allows for expenditure of funds "for ambulance service vehicles or vehicle equipment, emergency medical services supplies or equipment or emergency medical training ..." The statute continues by stating "funds allocated under this program shall supplement existing, budgeted moneys of or provided to an ambulance service provider and may not be used to replace, decrease or release for alternative purposes the existing, budgeted moneys of or provided to an ambulance service provider." (Refer to http://dhs.wisconsin.gov/ems/ for more information.) Return completed report to: Bureau of Local Public Health Practice and EMS, PO Box 2659, Madison, WI 53701-2659.
Expenses for State Fiscal Year : Name Of Service Address City
Service Fiscal Year : Provider No. Day Phone No.
Zip Code Title $
Name Of Contact Person (Chief, Director, Or Other Responsible Party)
Dollars Received For Year $ Escrow Amount From Prior Fiscal Years Reported CATEGORY TRAVEL
For training, call, etc.
Allocation Amount $ WHAT WAS PURCHASED?
Type of training, training officer wages, honoraria, etc.
Pagers, radios, etc.
Equipment under $500. Supplies limited to those not within existing budget.
Vehicle purchase (list). Vehicle maintenance an repair over and above existing budget
Purchase of items over $500 each. (List individual items).
ESCROW / SAVINGS
Money should be held in a separate account.
TOTAL FOR FISCAL YEAR
Total should equal appropriation plus any escrow carried over and being reported.
F-47257 (Rev. 01/09) Page 2
AMBULANCE SERVICE PROVIDER By my signature, I certify that the expenditure information listed for Fiscal Year 09 is true to the best of my knowledge. I further certify that EMS Funding Assistance Program funds received by this ambulance service have not been used to replace or decrease our existing budget/funding. I further understand that a similar expenditure report is due for every Fiscal Year from which our ambulance service receives funding and is due one year after receipt of the final check from that fiscal year.
SIGNATURE - Chief, Director or other responsible party
Name and Title (Type or print)
MUNICIPALITY By my signature, I certify that the EMS Funding Assistance Program funds received by the ambulance service identified in this expenditure report have not been used to replace or decrease budgeted funds previously made available by the municipality(s).
SIGNATURE -- Municipal Official
Name and Title (Type or print)
INSTRUCTIONS 1. This form F-47257 (Expenditure Report) must be completed for every fiscal year from which you received EMS-FAP funds. 2. Funds are provided by state fiscal year (SFY). The fiscal year is from July 1st through the following June 30th. 3. Do your best to identify what you used the EMS-FAP money for. Report only those expenditures using EMS-FAP funding. 4. Completing The Individual Expenditures List: Travel: Travel expenses incurred for training functions can be combined as can travel expenses for other individual functions. Training: Training expenses incurred for seminars can be combined as can training expenses for in-house training, honoraria or training officer wages. Communications: List what was purchased, i.e. pagers, portable radios, mobile radios, cellular phones, consultant time, etc. along with amount spent. Medical supplies: All purchases of equipment of under $500 each should be listed together as "Equipment under $500". The cost of medical supplies in excess of the existing budget should be combined and listed. Vehicle: Each vehicle purchase should be listed separately. Vehicle maintenance and repair costs in excess of the existing budget should be listed as one figure. Equipment: Purchases of equipment costing over $500 each should be listed here. Specify what has been purchased. Other: Specify items or groups of items not listed above. Escrow/Savings: Dollars not expended from the fiscal year appropriation being reported should be kept in a separate account and listed here. TOTAL: The total of all expenditures for the fiscal year, along with dollars being held in escrow or savings, should be equal to the total allocation for the fiscal year. 5. Refer to the Wisconsin EMS website for more information on the EMS Funding Assistance Program. 6. Return completed report to: Bureau of Local Public Health Practice and EMS PO Box 2659 Madison, WI 53701-2659