REQUEST FOR EXPENDITURE ______Regional Office ______TCM Entity

INDIVIDUAL’S NAME: ______DMH #: ______

PROVIDER: ______DATE: ______

ITEM(S) REQUESTED: ______

______

JUSTIFICATION FOR REQUEST: ______

AMOUNT REQUESTED: ______CURRENT BALANCE ______

CHECK MADE PAYABLE TO: ______

MAIL CHECK TO: ______

______

______Reimbursement ______Payment Up Front

______Support Coordinator Signature/Date Supervisor Signature/Date

*****************************************************************

______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

______Expenditure to be paid from Individual’s banking account at Regional Office.

______Expenditure to be paid with DMH funds via the SCL invoice

****************************************************************************************

REGIONAL OFFICE ______AUTHORIZES ______DENIES THE ABOVE EXPENDITURE AND REASONING:

______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.

Revised 1/8/14 Check # ______Check Date______B.O. Initials ______