Free Instructions for Completing CARS Expenditure Report, F-60855A, DMT-855a - Wisconsin

DEPARTMENT OF HEALTH SERVICES Divisin of Enterprise Services F-80855A (07/08)

STATE OF WISCONSIN

INSTRUCTIONS FOR COMPLETING EXPENDITURE REPORT, F-80855
Please Type or Print Completion of this form meets the requirements of s. 46.036, Wis. Stats. Failure to complete the form may result in non-payment of expenditures. Personally identifiable information on this form will be used only to process the form. Check the box to indicate type of expenditure report. The choices are Original Report, Additional Report or Final Report. There should be only one original report per report period. Corrections to previously reported periods should be made on additional reports. Agency Number Agency Name Contract Period Agency Type Agency Address Contract Administrator Report Period Contact Person and Telephone Number E-mail Address Profile Name Profile ID Number Total Enter the CARS agency number from the contract. Enter the name of the reporting agency. Enter the beginning and ending date of the contract period. Enter the one or two-digit agency type from the contract. Enter the mailing address of the reporting agency. Enter the name of the state contract administrator or program manager. Enter the beginning and ending date of the month covered by this report. Enter the name and phone number of the person preparing this report.

Enter the contact person's E-mail address For each total, enter the name of the CARS PROFILE. For each total, enter the CARS PROFILE ID. Total expenditures for this profile (if expense is negative, put parenthesis around the dollar amount). Enter breakdown of expenditures and revenues required by contract (e.g. Personnel Services, Program Supplies, Agency Operations...). Provide total line for each separate PROFILE ID. Total down each column (Personnel Services, Consult/Contract, Program Supplies, Agency Operations, Indirect Costs). Use as necessary. Enter the name and title of the authorized agency representative.

Category of Expenditure

Total Reported Expenses

Comments Name and Title of Authorized Representative Signature of Authorized Agency Representative Date Signed Distribution ­ Send to:

Enter the signature of the authorized agency representative. The original signature copy must be sent to the CARS Unit. Enter the date the report was signed. Division of Enterprise Services Bureau of Fiscal Services, Processing Section ­ CARS Unit PO Box 7850, Madison, WI 53707-7850

Retain a copy for your records and mail one copy to your Contract Administrator.