TOTALS

Please list your household expenses:

	Monthly Amount	3 Month Amount
Television/Home Phone/Internet
Television//Internet
Mortgage/Rent
Electric/Gas
Water/Sewage
Renters/Home Insurance
Auto Insurance
Car Payment
Cell Phone
Food
Toiletries/Cleaning products

This box will show the amount Needed for the 3 month reserve

Sponsor must maintain a minimum capital reserve fund or line of credit in the amount of three (3) times the sponsor's monthly operating expenses. Required so that services can be continued in the event of interruptions, delays in Medicaid funding, authorization disapprovals and/or reduction in funding or pay
MONTHLY TOTALS
3 MONTH TOTALS
Sponsor Name
Date

MonthDayYear
Date
Signature

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