<p> REQUEST FOR EXPENDITURE ______Regional Office ______TCM Entity</p><p>INDIVIDUAL’S NAME: ______DMH #: ______</p><p>PROVIDER: ______DATE: ______</p><p>ITEM(S) REQUESTED: ______</p><p>______</p><p>JUSTIFICATION FOR REQUEST: ______</p><p>AMOUNT REQUESTED: ______CURRENT BALANCE ______</p><p>CHECK MADE PAYABLE TO: ______</p><p>MAIL CHECK TO: ______</p><p>______</p><p>______Reimbursement ______Payment Up Front </p><p>______Support Coordinator Signature/Date Supervisor Signature/Date </p><p>*****************************************************************</p><p>______Expenditure of $100.00 or more from Individual’s personal funds located in the home. Per Division Directive 5.070 – Support Coordinator only required signature </p><p>______Expenditure to be paid from Individual’s banking account at Regional Office.</p><p>______Expenditure to be paid with DMH funds via the SCL invoice</p><p>****************************************************************************************</p><p>REGIONAL OFFICE ______AUTHORIZES ______DENIES THE ABOVE EXPENDITURE AND REASONING:</p><p>______Regional Director/Designee Signature/Date NOTE: THIS FORM IS VALID FOR (60) sixty days from date of authorized signature. For payment upfront receipts must be submitted within 30 days of consumer banking check date.</p><p>Revised 1/8/14 Check # ______Check Date______B.O. Initials ______</p>