Provider agencies that receive prospective payments must use the Summary Expenditure Documentation Form (EDF) to provide reporting of expenditures. The EDF may be photocopied or a reasonable electronic duplication developed. The amounts reported must be the total expenditures for the period for a single program. A separate EDF must be completed for each program.
- Person Completing Form - Contact person (Mandatory)
- Phone - List the phone number and extension for a contact person who will be able to answer questions concerning the submitted expenditure form. (Mandatory)
- Amount - Enter dollar amount for each month claimed. A report should be submitted even when no dollars are spent, to assure that there are no gaps in documentation. (Mandatory)
- Personal Services/Fringes - All provider agency staff whose salary and/or fringe benefits are paid in full or in part from grant funds for this program (fringe benefits are the employer's portion of fringe benefits actually paid on behalf of direct services employees).
- Contractual Services - This category includes such items as contractual employees or consultants, utilities, rent or lease of equipment, space or facilities, postage, repair and maintenance of furniture and equipment, software for support of program objectives, training and education costs, conference fees, membership dues/fees (agency memberships only), subscriptions.
- Travel - This category includes mileage, parking, per diem, meals, lodging and other associated travel items.
- Supplies - This category includes such items as office supplies, medical supplies, educational and instructional material and supplies, cleaning supplies, equipment items costing less than $100 each, printing.
- Equipment - Equipment costing $100 or over per item. Prior approval is necessary for equipment items costing $500 or above and having a useful life of more than one year (written approval must be given by Department program staff).
- MATCH - If required, please indicate the total dollar amount for MATCH.
- Components - Used in the WIC and Early Intervention Programs. (Optional)
Authorized Agency Official - This form must be signed and dated by an authorized official of the provider agency. (Mandatory)