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fiscal officers training manual - New York State Conference of Local ...

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CountyNEW YORK STATE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICESAID TO LOCALITIESPROGRAM BUDGET CHANGE REQUEST (PBCR) FORMAgency NameAgency CodePRU NumberProgram Code+Index<strong>Local</strong> Fiscal YearRevision #Budget Expense/Revenue CategoriesEXPENSES:Personal ServicesFICA & Fringe BenefitsO.T.P.S.EquipmentProperty/SpaceAgency AdministrationTotal Gross ExpensesCurrent Approved Requested ProgramBudget <strong>of</strong> Record BudgetColumn 1 Column 2$ChangeColumn 3%ChangeColumn 4REVENUE:Patient FeesSSI and SSAHome Relief/Public AssistanceMedicaidMedicare<strong>State</strong> GrantThird Party/Private InsuranceFederal GrantFood Stamps<strong>Local</strong> TaxOther Rev:Other Rev:Other Rev:Total RevenueNET OPERATING COSTDeficit Funding<strong>State</strong> Aid<strong>Local</strong> GovernmentNon-FundedTotal000Is this an on-going change?The following information MUST be completed, if applicable.Units <strong>of</strong> ServiceGross Cost per Unit <strong>of</strong> ServiceNet Cost per Unit <strong>of</strong> ServiceYESNOAgency ApprovalCounty Approval (if necessary)Signature:Signature:Title: Date: Title: Date:FIELD OFFICE APPROVALDISTRICT DIRECTOR APPROVALSignature:Signature:Title: Date: Date:DIRECTOR OF STATEWIDE FIELD OPERATIONS APPROVALSignature:Date:BUREAU OF BUDGET MANAGEMENT APPROVALSignature:Date:PBCR (03/07)

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