Fillable Printable Kansas General Affidavit Form
Fillable Printable Kansas General Affidavit Form
Kansas General Affidavit Form
KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT
AFFIDAVIT OF EXPENDITURES
PART C OF IDEA INFANT TODDLER SERVICES
GRANTEE NAME/TITLE OF AWARD:
Person who can answer questions regarding this report:
PHONE: REPORT PERIOD:
EXPENDITURE CLASSIFICATION
Total Salary % Part C Local
For Report Time Expenditure
SALARIES (Including fringe benefits)
Period Worked for Amount
List name & position of employee
Period
Sub-total Salaries
0.00
TRAVEL (provide brief detail)
Sub-total Travel
0.00
SUPPLIES (Itemize/provide brief detail)
Sub-total Supplies
0.00
CAPITAL EQUIPMENT (ITEMIZE)
(List each item, make, model, serial#; include copy of invoice)
Sub-total Capital Equipment
0.00
OTHER (ITEMIZE)
Sub-total Other
0.00
AFFIDAVIT TOTALS 0.00
The local agency administrator below certifies that this report is in agreement with the agency official accounting
records and that individual employee time reports are maintained documenting time charged to this program.
AUTHORIZED SIGNATURE: Date:
SFY2016 KDHE USE ONLY: __________ Audited by:___________ *Attach additional sheet(s) as necessary
KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT
AFFIDAVIT OF EXPENDITURES
PART C OF IDEA INFANT TODDLER SERVICES
Grant Total
Expenditure Expenditure
Amount Amount
0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00 0.00
0.00 0.00
SFY2016 KDHE USE ONLY: __________ Audited by:___________ *Attach additional sheet(s) as necessary
