Direct Payment Quarter 1 Return Sheet for Financial Year 2015/2016 Service User’s First Name Service User’s Surname ………………………………….. ………………………………….. Service User’s Address …………………………………………………………………………………………………………... DIRECT PAYMENTS QUARTERLY RETURN 1 A B C D E F INVOICES/RECEIPTS WEEK WEEK COMMENCING PAYMENTS RECEIVED EXPENDITURE INCURRED NOTES ATTACHED 1 30-Mar-15 2 06-Apr-15 3 13-Apr-15 April 4 20-Apr-15 5 27-Apr-15 6 04-May-15 7 11-May-15 May 8 18-May-15 9 25-May-15 10 01-Jun-15 11 08-Jun-15 12 15-Jun-15 June 13 22-Jun-15 G H I J If Original Bank Statements to be Returned Balance From Previous Quarter Total In Total Out Balance at End of Quarter Please Tick Box: TICK: The information stated is an accurate record of expenditure which I have incurred in relation to my agreed package for the above weeks. Signed: Date: ……………………………………….. ……………………………………….. ECC11210 Page 1 of 4
Direct Payment Quarter 1 Return Sheet for Financial Year 2015/2016 Service User’s First Name ………………………………….. Service User’s Surname ………………………………….. Service User’s Address …………………………………………………………………………………………………………... DIRECT PAYMENTS QUARTERLY RETURN 1 A B C D E F WEEK WEEK COMMENCING PAYMENTS RECEIVED EXPENDITURE INCURRED INVOICES/RECEIPTS ATTACHED NOTES 1 30-Mar-15 April 2 06-Apr-15 3 13-Apr-15 4 20-Apr-15 5 27-Apr-15 May 6 04-May-15 7 11-May-15 8 18-May-15 9 25-May-15 10 01-Jun-15 June 11 08-Jun-15 12 15-Jun-15 13 22-Jun-15 G H I J Balance From Previous Quarter Total In Total Out Balance at End of Quarter If Original Bank Statements to be Returned Please Tick Box: TICK: The information stated is an accurate record of expenditure which I have incurred in relation to my agreed package for the above weeks. Signed: ……………………………………….. Date: ……………………………………….. ECC11210 Page 1 of 4
Quarter_one_return_15-16.docx