* = Required Information
Client Name
*
Month/Year
*
There must be a receipt for every transaction attached to a separate page
Be specific with description of transactions (use several lines if necessary)
Date
Ref. #
Description of Transaction (WHAT was purchased)
Withdrawal
Deposit
Remaining Balance
Add Another Field
Total Withdrawal
Total Deposit
Total Remaining Balance
End of the Month Balanced and Checked for Accuracy:
Lead Counselor Signature and Date
*
Accounting Department/Date
*
Submit