Direct Payment Quarter 4 Return Sheet for Financial Year 2014/2015 Service User’s First Name Service User’s Surname ………………………………….. ………………………………….. Service User’s Address …………………………………………………………………………………………………………... DIRECT PAYMENTS QUARTERLY RETURN 4 A B C D E F INVOICES/RECEIPTS WEEK WEEK COMMENCING PAYMENTS RECEIVED EXPENDITURE INCURRED NOTES ATTACHED 40 29-Dec-14 41 05-Jan-15 42 12-Jan-15 January 43 19-Jan-15 44 26-Jan-15 45 02-Feb-15 46 09-Feb-15 47 16-Feb-15 February 48 23-Feb-15 49 02-Mar-15 50 09-Mar-15 51 16-Mar-15 March 52 23-Mar-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 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 4 of 4
Direct Payment Quarter 4 Return Sheet for Financial Year 2014/2015 Service User’s First Name ………………………………….. Service User’s Surname ………………………………….. Service User’s Address …………………………………………………………………………………………………………... DIRECT PAYMENTS QUARTERLY RETURN 4 A B C D E F WEEK WEEK COMMENCING PAYMENTS RECEIVED EXPENDITURE INCURRED INVOICES/RECEIPTS ATTACHED NOTES 40 29-Dec-14 January 41 05-Jan-15 42 12-Jan-15 43 19-Jan-15 44 26-Jan-15 February 45 02-Feb-15 46 09-Feb-15 47 16-Feb-15 48 23-Feb-15 49 02-Mar-15 March 50 09-Mar-15 51 16-Mar-15 52 23-Mar-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 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 4 of 4
Quarter_four_return.docx