Free 24220.pdf - Indiana

MONTHLY REIMBURSEMENT CLAIM FOR TITLE IV-D EXPENDITURES
State Form 24220 (R5 / 12-99) / FM 0920 Financial Management Family and Social Services Administration 402 West Washington St., P.O. Box 7128 Indianapolis, Indiana 46207-7128

INSTRUCTIONS: Submit completed form with State Form 24221/FM 0919 (on reverse) to Financiai Management at the address listed above by the 10th of the month.
Month / Year County Agency (check one)

Prosecutor 1. PERSONAL SERVICES 101 102 SALARIES AND WAGES EMPLOYEE BENEFITS TOTAL 102A 102B 102C 102D 102E SOCIAL SECURITY RETIREMENT INSURANCE UNEMPLOYMENT OTHER (specify) $ $

Clerk

IV-D Court

TOTAL PERSONAL SERVICES 2. SUPPLIES 201 202 OFFICE SUPPLIES OTHER

$

TOTAL SUPPLIES 3. OTHER SERVICES AND CHARGES POSTAGE 301 TRAVEL (Attach copy of Travel Voucher) 302 TELEPHONE 303 PRINTING 304 LEGAL NOTICE 305 COPY SERVICES 306 MAINTENANCE OF EQUIPMENT 307 BONDS AND INSURANCE 308 RENT 309 UTILITIES 310 DUES AND SUBSCRIPTIONS 311 DATA PROCESSING CHARGES 312 EQUIPMENT RENTAL 313 OTHER (specify) 314 TOTAL OTHER SERVICES AND CHARGES 4. CAPITAL OUTLAYS (Attach FM 0910) 401 FURNITURE AND FIXTURES 402 OFFICE MACHINES 403 OTHER (specify) TOTAL CAPITAL OUTLAYS *** GRAND TOTAL OF ALL EXPENDITURES 5. PROGRAM INCOME INTEREST EARNED (Title IV-D cases only) *** NET TOTAL EXPENDITURES (Grand Total Expeditures Minus Interest Earned) CERTIFICATION

$

$

$ $ $ $

I certify that the expenditures as specified above together with the reported program income is a true and accurate account of the program income and lawful expenditures authorized by the Child Support Bureau during the above described month.
Signature of Authorized Official Person preparing the claim Telephone Date

FOR FM USE ONLY:
Reimbursement at 100% $ Comments: Balance $ Reimbursement paid at FFP rate $ Paid: $ Total reimbursement $