To document an expenditure request for a resident's trust fund. Form 4143-CC is used to order and obtain services or goods for a resident when the invoice/bill will be paid directly by the Corpus Christi State Supported Living Center's Business Office trust fund clerk.
When to Prepare
Home staff prepare this request when a resident wants or needs a personal item, or when a parent/guardian/legally authorized representative (LAR) wants or needs an item for a resident as part of the resident's Individual Support Plan (ISP), approved by the resident's Individual Support Team (IST).
Number of Copies
Original to the trust fund clerk and copies to the Qualified Developmental Disabilities Professional (QDDP)/social worker.
After all signatures are obtained and the goods/services are obtained, the original form is returned to the trust fund clerk.
The trust fund clerk must retain a copy of this form in the individual's trust fund records per records retention standards.
Purpose — Check the box indicating the purpose of the expenditure request: Regular, Repair, Christmas or Birthday.
Resident's Name — Enter the resident's last name, first name and middle initial.
Resident No. — Enter the resident's case number.
Home — Enter the name of the resident's home.
Items — Enter the name of the item(s) requested and approved by the IST and complete the appropriate blocks: Quantity Ordered, Size, Color, Quota, Quantity on Hand, Estimated Cost. In the item column, enter the name of the vendor, if known.
Resident Requested Items — Enter the name of the items requested by the resident. Enter the vendor name in the item column and complete the appropriate boxes: Quantity Ordered, Size, Color, Quota, Quantity on Hand, Estimated Cost.
Person Placing Order, Title, Date and Total Estimated Cost — Enter the name and title of the person placing the order, the date and total estimated cost.
Social Worker/QDDP Signature and Date — The social worker/QDDP approving the order for the resident signs and dates the form.
Purchaser/Title and Date — Enter the name of the purchaser and title of the person who submits the order and/or makes the direct purchase of the item(s). The entry date represents the date of the request, not the date of the actual order/purchase, although those two dates could be the same.
Home Supervisor (or other approver)/Title and Date — Enter the supervisor's name and date of approval.
Resident's Signature/Mark or "UTS" and Date — The resident signs and dates the form. If the resident is unable to sign, enter "UTS" for the resident.
Trust Fund Clerk and Date — Enter the name of the trust fund clerk and date.
Witness Signature, Title and Date — Two persons sign and date the form as witnesses of the resident's signature, mark or "UTS" entry (one witness signature is acceptable).
Amount Approved, Received from Trust Fund and Control Number — The trust fund clerk enters the information at the end of the expenditure process.