Effective Date: 




Updated: 3/2013



To document funds withdrawal from a resident's trust fund account.



When to Prepare

Form 4141-CC is prepared by the home manager or home staff and approved by the Qualified Developmental Disabilities Professional (QDDP)/social worker assigned to the resident. Form 4141-CC can also be prepared by the QDDP/social worker with approval by the home manager/unit director. The form is prepared in advance of the needed funds (in the form of cash or a check). Form 4141-CC should be completed and submitted at least three business days in advance of the needed funds to ensure that approval signatures are obtained prior to the issue and receipt of the funds. This form is used for reimbursement for:

  • parents/legally authorized representatives (LARs);
  • vendor payments;
  • weekly resident personal spending;
  • other spending requests;
  • pre-placement/furlough spending; and
  • expenses related to community placement.

Funds for multiple residents can also be withdrawn at the same time using Form 4141-CC.

Number of Copies

Original to the trust fund clerk and a copy to the person receiving the funds.


After all signatures are obtained, including approval by the trust fund clerk, the funds will be issued by the cashier. Receipt of the funds is acknowledged by signature on the form.

Form Retention

The trust fund clerk must retain a copy of this form in the individual's trust fund records per records retention standards.


Detailed Instructions

Date Funds Needed — Enter the date.

Unit — Enter the unit.

Home — Enter the home.

Check Appropriate Box — Check the appropriate box or boxes, including the statement of responsibility box.

Purpose of Funds Requested — Enter the purpose, i.e., weekly spending, reimbursement to parent, community placement, etc.

Funds Requested By — Obtain all required signatures and the date acknowledging approval of the request. Upon receipt of the funds, the last signature is the person responsible for the cash/check.

Check Number — Self-explanatory.

Case No., Resident's Full Name, Amount, Resident's Signature, Witnessed By/Title, Amount Spent and Amount Redeposited — Complete these entries for single or multiple residents. If the resident is able to sign, obtain the resident's signature as cash is issued to him or her. If the cash goes to a vendor, then the amount to be redeposited (if any) is entered in the last column.

Received/Audited by Cashier, Date and Receipt No. — These entries will be made by the cashier when issuing the cash or check.

Date and Total Redeposited — The last two entries will be completed if and when any unspent funds are returned to the cashier. The entries will be completed by the responsible person in receipt of the funds. The cashier will initial the Total Redeposited box to confirm receipt of the cash.

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