MONEY MANAGEMENT BILL PAYER - TIME AND MILEAGE CONTACT LOG

MONTH / YEAR

(Use tab to navigate from field to field)

Do you want reimbursement for mileage and other expenses? No Yes

Other expenses: (postage, copying, parking, etc.) $

                              Reimbursement requests must be received on the 4th day of the month in order to be compensated.

STATUS OF CLIENT MONTHLY SUMMARY
BILL PAYER

1. Are all checks accounted for? Yes No

2. Was bank statement reconciled this month? Yes No

3. Does the signature on the checks match the clients? Yes No

4. Is the bank balance within  guidelines? Yes No

5. Any questionable withdrawals or expenses? Yes No

6. Are normally expected deposits being made? Yes No

7. Are checks being direct deposited? Yes No

8. Any unusual expenditures or cash payments? Yes No

9. Community supports (if used) adequate? Yes No
(If assistance needed, note in remarks)

10. Is client's physical/mental health stable? Yes No

11. Is client still making good financial decisions? Yes No

Please elaborate on above questions as needed and Indicate any unmet needs, services or concerns that are not addressed above.