Direct Payment Quarter 3 Return Sheet for Financial Year 2014/2015 Service User’s First Name Service User’s Surname ………………………………….. ………………………………….. Service User’s Address …………………………………………………………………………………………………………... DIRECT PAYMENTS QUARTERLY RETURN 3 A B C D E F INVOICES/RECEIPTS WEEK WEEK COMMENCING PAYMENTS RECEIVED EXPENDITURE INCURRED NOTES ATTACHED 27 29-Sep-14 28 06-Oct-14 29 13-Oct-14 October 30 20-Oct-14 31 27-Oct-14 32 03-Nov-14 33 10-Nov-14 34 17-Nov-14 November 35 24-Nov-14 36 01-Dec-14 37 08-Dec-14 38 15-Dec-14 December 39 22-Dec-14 G H I J If Original Bank Statements to be Returned Balance From Previous Quarter In Total Out Balance at End of Quarter Please Tick Box: TICK: The information stated above is an accurate record of expenditure which I have incurred in relation to my agreed package for the above weeks. Signed: Date: ……………………………………….. ……………………………………….. ECC11210 Page 3 of 4
Direct Payment Quarter 3 Return Sheet for Financial Year 2014/2015 Service User’s First Name ………………………………….. Service User’s Surname ………………………………….. Service User’s Address …………………………………………………………………………………………………………... DIRECT PAYMENTS QUARTERLY RETURN 3 A B C D E F WEEK WEEK COMMENCING PAYMENTS RECEIVED EXPENDITURE INCURRED INVOICES/RECEIPTS ATTACHED NOTES 27 29-Sep-14 October 28 06-Oct-14 29 13-Oct-14 30 20-Oct-14 31 27-Oct-14 November 32 03-Nov-14 33 10-Nov-14 34 17-Nov-14 35 24-Nov-14 36 01-Dec-14 December 37 08-Dec-14 38 15-Dec-14 39 22-Dec-14 G H I J Balance From Previous Quarter In Total Out Balance at End of Quarter If Original Bank Statements to be Returned Please Tick Box: TICK: The information stated above is an accurate record of expenditure which I have incurred in relation to my agreed package for the above weeks. Signed: ……………………………………….. Date: ……………………………………….. ECC11210 Page 3 of 4