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19
<br /> LOCAL HEALTH DEPARTMENT B
<br /> N.C.Department of Human Resources • etS 4
<br /> ilk 4 zp_, Revision Number____
<br /> Miterztal and Chtik1 Care 4." '."." ,,
<br /> Division of Health Services
<br /> timt,
<br /> Office,Section or Branch 'I, //989 Yz*3\
<br /> :2;.3
<br /> rr ....: P.O.Number
<br /> itonottrro. ....
<br /> 07/ 89 06 / 90 :::.
<br /> ___
<br /> _6
<br /> ...' SfOrm--....+
<br /> Effective Date Termination Date
<br /> Contract Number
<br /> e
<br /> Contractor: Orange County Health Department Activity: Virtritinn Titlp XX ___ __
<br /> Project Director: Daniel B. Reimer
<br /> Total Budget:$ 2,119.50 (150 x 14.13)
<br /> ITEM DESCRIPTION CLASSIFICATION ITEM AMOUNT
<br /> E STATE EXPENDITURES: — '' """'OrprAnenriT.WW-44Z001-,Th•.- '.tirls.-1...e::4%it',::‘,4-:
<br /> KANnii:4-::::14 ...,,.,,, P.WI:
<br /> WIl'i,`VrOz4:::,:ys:N: n;:s1-vi.:4":..0",.**.. . -v:'.•.fv.,44,,,%.4 444, ::' ;r4f5:...e,IA:3.512.''4.rire ...,Itt
<br /> t*...%-.PAW: '.44'4,47:, :;,vt s;,.:4,. •: ,-9 ,,...04,.*:::'¢:, 49."' '.,..4b,",' '9:',N6,03,fit.":".
<br /> SaLsries 6t. Fringe Benefits Operating Expenses ,t,.,.k....-:.:.::.:,m. -0.,.:y..•:.T.L:4--4z:yi.z.v:4..0,.,-........f.:,&&.1. .::.
<br /> .*Paa:::, :aNtlier: 1.-. :1.7-T,
<br /> tf::,:,-:-:.:.,...7.,:ii.:.y.,..,:_..gfawiATT:c:7:47.::::.7,4,-.4...:,0'..z
<br /> P Purchase of Equipment , . ,..„.jg,liat..,..:. ---:„.?.,
<br /> t.44:::„.•.:,:'''NA5i;.,:: :::::;::::::::::!'•'''.1::;41::#4.rir:4;*";.7::;:i,..irM94:44,07.e.WilattaRate
<br /> E General Contracted or roisests,: w.4.,:irop*, w.s.:...,..,.:.,,:.„,47,,.'::.#,Ait AsapiTAA*..`wftfttatpAgagaxt-mt
<br /> Purchased Services vrif..::.•,.-..-,:-:•;;?.";.::',;.'0:::::::...i:---."-r *4.:, •zotniglitimp..,:ti.....:.:Icgrav:;:m:Nozat.A.,
<br /> School Health k:'':FPC ilFk,A.,ASME.Y.:-..S..4.,A.::
<br /> :f..44-4,, 1.L.k7:t''1.'',,t:','iViOft.,...,V,&.„,,
<br /> D Cknictian 4,-,iv..,,,.,,. :-.,--k, -. -,..k,,,.....::.,..
<br /> I Delivery Services '.77*
<br /> ,: :^7,:::.,''-i ,AWN:77T:.::::+"...*'if'..'!"*.7:4'1'''.i.•,;:::;Te*tr-F15.044.70tlizeit
<br /> es
<br /> ,,,k,"-::".:.•....i.-..-.....• - ..," ,,,,,.....--,:-•.. ... • .....„;. ••....4 :•.,: '6•r.%.::.,i, :"..>',,:::::::,
<br /> Laboratory tiE7,iiatialiF4'. ..d.:Natr •; i',.,.7:‘:''..',,-:::'-fmw,
<br /> T Pharmacy Services iz„...,.,-7....:.,.7.;-:.:7::rx_.,KwaogAgy ::71,30w.,:g..-7, 4c:.,1,--13. 4,,:gozatiti,g0
<br /> FC;Z:. .,.%..1. 7-. 1:-.... .iin.....:.....>.,I=,?-,:,75:. 7,.; ':,,.7,.,72.;,,,....0::
<br /> U Transfer TXDC/SSBG arMI ,...' : ',400 afiL‘,.. .,1:,4: 1*.:,,I.:::,,p,,,..
<br /> R Subtotal State Expend. — $
<br /> E LOCAL EXPENDITURES: LOCAL EXP 9000 150 x 14.13 2,119.50
<br /> S
<br /> TOTAL EXPENDTI1JRES—equal to Total Receipts $ 2,119.50
<br /> ,
<br /> . —
<br /> R LOCAL FUNDS:
<br /> Appropriation - APPROP_ ELilax 3.88) 582.00
<br /> E TXIX/SSBG Fees - _____102 (1 )x 10.25) 1,52700
<br /> c , Other Receipts OTHR. REC 103
<br /> E Subtotal Local Funds
<br /> (101 +102) $ 2,119.50
<br /> i STATE/FEDERAL/SPECIAL FUNDS:
<br /> P
<br /> T
<br /> S _
<br /> Subtotal State/Federal/Special
<br /> $
<br /> TOTAL RECEIPTS—equal to Total Expenditures $ 2,119.50
<br /> . ,
<br /> Local Authorized Official Signature Date Branch Head
<br /> kifid DHS Section Chief Sigtature Date
<br /> Finance Officer Signature Date - AMMard DHS Budget Officer Signature
<br /> lakiel Date
<br /> DHS 2948(Revised 2/87)
<br /> Contracts Administration(Review 2/90)
<br />
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