Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Divisin of Enterprise Services F-80862A (07/08)

STATE OF WISCONSIN

INSTRUCTIONS FOR COMPLETING EXPENDITURE REPORT, F-80862
Please Type or Print 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 Program Name Agency Type Agency Address Contract Administrator Report Period Contact Person and Telephone Number Contract Period E-mail Address Category of Activity Enter the CARS agency number from the contract. Enter the name of the reporting agency. Enter the name of the program providing funds for the reporting agency. 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 beginning and ending date of the contract period. Enter the contact person's E-mail address Enter breakdown of expenditures and revenues required by contract (e.g. Admin. Expenses, Support Expenses...). Provide total line for each separate PROFILE ID. For each total, enter the name of the CARS PROFILE. For each total, enter the CARS PROFILE ID. Enter current month expenditures for each line of activity. Used to enter information into the CARS system. Enter the contract to date expenditures for each line of activity. Used to enter information into the CARS system. Enter total contract of budget amount allocated to each line of activity. Complete as instructed by contract administrator or program manager. Total down each column. Enter the name and title of the authorized agency representative.

Profile ID Name Profile ID Number Current Month Expenditures Contract to Date Expenditures Budget / Contract Amount
Contract to Date Expenditures (Agency Share)

Total Reported Expenses 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