BILLING AND ROUTING SHEET
TRANSITIONAL EMPLOYMENT ASSISTANCE PAYMENTS
BILLED TO THE DEPARTMENT OF HUMAN SERVICES
| Section A
WISE Reimbursement WISE NON-Reimbursement Check # Diversion Payment Relocation Payment (If Known)
Person/Provider to Be Paid: SSN/VIN |
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Section B Address: |
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GOODS, SERVICES, TRANSPORTATION EXPENSE, MISCELLANEOUS COSTS AND\OR ASSISTANCE PROVIDED (Section E, Page 2 (on back) must be completed to be reimbursed for Personal Mileage and Miscellaneous Costs.) |
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Description: |
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(If more lines are needed, complete Section B-Attachment) Total Payment |
$ |
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(Reporting these expenses does not guarantee that you will be reimbursed) |
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Section C (See Section C of the Instructions to Determine Who Should Sign for DHS Authorization) |
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I certify that the information reported on this form is correct; that all expenses or assistance was incurred while participating in TEA; that the goods and/or services have been received and/or rendered, or that the assistance provided is allowable. |
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Signature Client/Provider/Vendor: |
Date: |
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Official Title: |
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DHS Authorized Signature: |
Date: |
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Official Title: |
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Section D
Required Supporting Documents and Submission Instructions:
If payment is being made for reimbursement of expenses other than mileage and miscellaneous costs, attach a receipt marked "PAID".
To pay a provider/vendor directly, attach an original and two copies of the invoices or bills.
(If the provider/vender is an individual,Section B may be completed in lieu of a hand written invoice. If this is done, the provider/vender’s signature is required in section C.)
For Diversion and Relocation payments, see Section D of the instructions. For all other payments, mail this completed form and the required documentation to:
Department of Human Services
General Operations Section, Program Support
P.O. Box 1437, Slot 3220
Little Rock, AR 72203-1437
County Office Worker Name Telephone Number
Section E
TRANSITIONAL EMPLOYMENT ASSISTANCE
PERSONAL MILEAGE AND MISCELLANEOUS COST REIMBURSEMENT
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DATE |
MISCELLANEOUS COSTS (OTHER THAN MILEAGE) |
TRAVEL BY PRIVATELY OWNED VEHICLE |
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YR ________ |
INCIDEN- |
TELE- |
TOTAL |
BETWEEN WHAT POINTS |
MILEAGE DRIVEN/ # OF TRIPS |
RATE PER MILE/TRIP |
AMOUNT |
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Mo |
Day |
MEALS |
TALS* |
PHONE |
PER DAY |
FROM |
TO |
CLAIMED |
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TOTAL MISC. COST |
$ |
TOTALS FOR MILEAGE |
$ |
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*Incidentals: (1) Postage (2) Parking Fee (3) Newspaper SUMMARY
(4) Other (Explain:________________________)
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MISC. COST |
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MILEAGE CLAIMED |
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TOTAL CLAIMED |
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BILLING AND ROUTING SHEET
TRANSITIONAL EMPLOYMENT ASSISTANCE PAYMENTS
BILLED TO THE DEPARTMENT OF HUMAN SERVICES
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Section B (Continued)GOODS, SERVICES, TRANSPORTATION EXPENSE, MISCELLANEOUS COSTS AND\OR ASSISTANCE PROVIDED |
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Description: |
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Enter this amount on last line of Section B, page 1. |
Sub-Total |
$ |
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DHS-0187 (3/99)