WV Bureau  For Behavioral Health & Health Facilities
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Flexible Funds
Expenditures Report
 
 
Behavioral Health Center:        
Report Submitted By:                
Report Due Date:                    (example: October 15, 2004)  
 
Consumer 1     Discharge Date  Expenditure  Amount   Balance
Consumer 2     Discharge Date  Expenditure  Amount   Balance
Consumer 3     Discharge Date  Expenditure  Amount   Balance
Consumer 4     Discharge Date  Expenditure  Amount   Balance
Consumer 5     Discharge Date  Expenditure  Amount   Balance
 
Ending Balance
Comments/Explanation: