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MO 580-1497 (06-05) DH-37
Agency Name: Fiscal Year:
2016
Agency Fiscal Year Previous Year Ending Balance
From: Through:
Month Day Year Month Day Year
Local Revenues DHSS Revenues Federal State Other
Local Taxes Core Public Health
Interest MCH
Vital Records School Health
Donations WIC Administration
Fees Child Care Inspections
Other Total (attach detail)
$0.00
Child Care Nurse Consultant
Total Local Revenue $0.00
AIDS Funding
PHEP
Other Revenues
Medicaid/MC+ (non Home Health)
Chronic Disease Prevention
Medicare (non Home Health)
Worksite Inventory
Family Planning Title X, etc.
Immunizations/Vaccine
Other DHSS Total (attach detail)
$0.00 $0.00 $0.00
Insurance Billing
Total DHSS Revenue
$0.00 $0.00 $0.00
$0.00 Total DHSS Funding $0.00
Home Health (all pymt. Sources)
$0.00
Home Maker (all pymt. Sources)
$0.00
Total Other Revenues
$0.00
Accrual Basis Adjustment (+ -)
Balance on hand as of the close of the fiscal year.
$0.00
(Balance at the end of previous fiscal year, plus revenues, minus expenditures)
Expenditures Expenditures from Local Funds
Salaries/Wages
Total Expenditures $0.00
Fringe Benefits
Less actual expenditure of DHSS funds. $0.00
Supplies/Equipment
Less actual expenditure of Other source funds. $0.00
Contracted Services
Less actual expenditure for Capital costs. $0.00
Travel
Utilities/Rent
Election Costs
Capital Expenditures
Other Total (attach detail)
$0.00
Total Expenditures $0.00 TOTAL LOCAL PUBLIC HEALTH EXPENDITURES $0.00
BCCCP/Show Me Healthy
Women
Other MO Departments (DOC,
DESE, etc.)
Other Public Health Revenue
Total (attach detail)
TOTAL REVENUES (from all sources)
Other Non-Public Health Revenue
Total (attach detail)
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
LOCAL PUBLIC HEALTH AGENCY
ANNUAL FINANCIAL REPORT