ࡱ> '` cbjbj{P{P 4:: QHHH8:HH_uhJ^RtRtRtROSUWNtPtPtPtPtPtPt$vh/yttG_OSOSG_G_tttRtRugggG_tRtRNtgG_NtggV i@bi tRJ 谁 H_Ji it /u0_uVi yo`zyniynilXZ0g[\XXXttttbXXX_uG_G_G_G_d.~?~? STATEMENT OF EXPENDITURESORIGINAL DHS RECEIPT DATE (For DHS Use Only)1. Contract NumberMichigan Department of Human Services See instructions on reverse side. See P.A. 431 information and non- discrimination statement on reverse side. FORMTEXT        FORMTEXT        FORMTEXT      SECTION I  Complete for all Submittals1A. Name of Contractor2. Index3. PCA4. Obj5. County FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      6. Period Covered by Statement7. Appn Yr2A. Index3A. Additional PCA sFROM: FORMTEXT      THRU: FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT      8. F.E. Number (or) Social Security Number9. Mail Code10. Contract Administrator Signature10a. Approval Date FORMTEXT       FORMTEXT       FORMTEXT      SECTION II  Bill Type11. Authorized DHS Approval Signature(s) (PAL)11a. Approval Date FORMCHECKBOX  ORIGINAL  FORMCHECKBOX  ESTIMATED FORMCHECKBOX  REVISED  FORMCHECKBOX  ADDITIONAL FORMCHECKBOX  FINAL  FORMTEXT      11b. Authorized DHS Approval Signature(s) (PAL) PRINTEDSECTION III  Dollars Expended to Provide Service to Eligible ClientsLISTED LINE ITEM BUDGETDOLLAR AMOUNT(Listed as specified in BudgetExpendedCumulativeContained in Agreement to PurchaseIn BudgetThis PeriodExpenditures to Date(1)(2)(3)(4)Salaries FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00Fringe Benefits FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00Occupancy FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00Communication FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00Supplies FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00Equipment FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00Local Transportation FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00Contractual Services FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00Specific Assistance to Individuals FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00Miscellaneous FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00TOTALS FORMTEXT  =SUM(ABOVE) 0.00.00 FORMTEXT  =SUM(ABOVE) 0.00.00 FORMTEXT  =SUM(ABOVE) 0.00.00SECTION IV Units Rendered to Provide Service to Eligible ClientsTYPE OF SERVICE (1)Contract Rate Per Unit (2)Number of Units Contracted (3)Units Provided This Period (4)Payment Amount This Period (5)Cumulative Units to Date (6)Cumulative Amount to Date (7) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT 0.00 FORMTEXT 0.00 FORMTEXT 0.00TOTALS FORMTEXT  =SUM(ABOVE) 0.00.00 FORMTEXT  =SUM(ABOVE) 0.00.00 FORMTEXT  =SUM(ABOVE) 0.00.00UR/AC GRAND TOTALS =SUM(total2,total4) \# "0.00" \* MERGEFORMAT 0.00 =SUM(total3,total6) \# "0.00" 0.00I hereby certify that the expenditures as stated in Section III represent actual expenditures made in accordance with the contract budget DHS-468; or that units of service provided as stated in Section IV have been provided.Contractor Signature Date FORMTEXT      INSTRUCTIONS Please Type or Print. Section I  Complete for all submittals Section II  Complete for all submittals Section III  Complete for line item reimbursement only Section IV  Complete for unit cost reimbursement SECTION I1.Contract Number fill in the complete contract number, including the letter prefix as it appears in the upper right hand corner of the contract.1A.Name of Contractor - fill in the contractor name exactly the way it is listed on the front page of your contract.2., 2A.Index Fill in the five digit index number for the expenditure. Use 2A if additional index is needed.3., 3A.P.C.A. Fill in the five digit program cost account for the expenditure. Use 3A for multiple PCAs.4.A. Obj. Fill in the four digit object code appropriate for the expenditure.5.County County name.6.Period Covered by Statement fill in the beginning and ending date of the service period covered by this statement.7.App. Year - Fill in the four digit appropriation year that funds are to be expended from.8.Federal Employer Number (or) Social Security Number fill in your federal identification number as it appears on Federal tax information. This is a nine digit figure. If you have no federal identification number your social security number may be used.9.Mail Code Fill in the three digit mail code which corresponds to the mail address.10.Contract Administrator To be completed by the Department.11.Authorized DHS Approval Signature(s) (PAL) to be completed by the Department.10A., 11A.Approval Date to be completed by the Department.11B.PRINTED Authorized DHS Approval Signature (PAL)SECTION II1.Original, Revised, Final, Estimate and Additional check the appropriate box.SECTION III(Col. 1)Line Item Budget Budget categories are listed exactly in the order that they appear on the DHS-468, Budget Statement.(Col. 2)In Budget fill in the amounts allocated for each category in the contract. Amounts must adhere to approved line item changes, if any.(Col. 3)Expended this Period fill in the amount spent for each category in the period you are billing the department by actual expenditures of each line item. 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" 0d$If *d$IfekdX$$If94FY&+ N    4 9af4yt8- "!"$"""".#gPkdZ$$If940*+c}(4 9af4yt8- 0d$If=kdY$$If94++4 9af4yt8-.#/#7#### $TPkdZ$$If940*+c}(4 9af4yt8- 0d$IfPkdZ$$If940*+c}(4 9af4yt8- $ $$^$_$b$x$TPkd[$$If940*+c}(4 9af4yt8- 0d$IfPkdk[$$If940*+c}(4 9af4yt8-x$y$|$$$$P%TPkd\$$If940*+c}(4 9af4yt8- 0d$IfPkdS\$$If940*+c}(4 9af4yt8-P%Q%T%R&S&V&&TPkd]$$If940*+c}(4 9af4yt8- 0d$IfPkd;]$$If940*+c}(4 9af4yt8-&&&&&&A'TPkd^$$If940*+c}(4 9af4yt8- 0d$IfPkd#^$$If940*+c}(4 9af4yt8-A'B'N'''''TPkd_$$If940*+c}(4 9af4yt8- 0d$IfPkd _$$If940*+c}(4 9af4yt8-'''''g^ 0d$If=kdg`$$If94++4 9af4yt8- d$IfPkd_$$If940*+c}(4 9af4yt8-'''(((g^ d$IfPkd#a$$If940*+c}(4 9af4yt8- 0d$If=kd`$$If94++4 9af4yt8-(('(((1((z=kda$$If94++4 9af4yt8- 0d$If=kda$$If94++4 9af4yt8-(((;)<)E))TPkdb$$If940*+c}(4 9af4yt8- 0d$IfPkdSb$$If940*+c}(4 9af4yt8-E)Z)) l '9T;T/9 -./UV\]^_abch\R70J8mHnHu h 0J8jh 0J8Uh\R7h}'jh}'Uh>1h hh>1h>1h h 5CJ h CJUh h 52)))TK d$IfPkdc$$If940*+c}(4 9af4yt8- 0d$IfPkd;c$$If940*+c}(4 9af4yt8-Cumulative Expenditures to Date fill in the amount you have spent from the beginning date of the contract, including this billing period.SECTION IV If contract is paid by unit rate, complete ONLY Section IV.(Col. 1)Type of Service fill in the definition(s) of unit(s) as stated in the contract under Section II, Contractor Responsibilities.(Col. 2)Contract Rate Per Unit fill in the payment rate of each service as stated in the contract under Section III, Department Responsibilities Payment.(Col. 3)Number of Units Contracted fill in the total number of units for each service this contract will allow as stated in the contract under Section II, Contractor Responsibilities.(Col. 4)Units Provided this Period fill in the number of units for each service used in this billing period.(Col. 5)Payment Amount this Period fill in the dollar amount of the units used in this billing period. This is the product of the contract rate per unit times the units provided this period. Total column, this is the amount you should expect to be paid.(Col. 6)Cumulative Units to Date fill in the total number of units used from the effective date of this contract to date.(Col. 7)Cumulative Amount to Date fill in the amount spent from the effective date of the contract to date. Total column. SIGNATURE Signature of person administratively responsible for the contract.Original to Contract Payment Unit, Suite 1018, Grand Tower Building, Lansing Copy to Contractor; copy maintained by Contract AdministratorDepartment of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.AUTHORITY: P.A. 280 1939. COMPLETION: Mandatory. PENALTY: No payment processed.     DHS-3469 (Rev. 6-10) Previous edition obsolete. 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