Exhibit A-Receipts And Disbursements

EXHIBIT A: RECEIPTS AND DISBURSEMENTS (1) Account: (2) Accounting Period Opening Date: RECEIPTS SUMMARY: (8) Category # Category Name $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Category Name $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Amount (3) Closing Date: Amount (9) Total Receipts: DISBURSEMENTS SUMMARY: (10) Category # (11) Total Disbursements: Page 1 of 3 Revised September 2004A Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.USCourtForms.com (4) ITEMIZED RECEIPTS: Category Date Payer Description $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Amount (5) Total Itemized Receipts: Page 2 of 3 Revised September 2004A Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.USCourtForms.com (6) ITEMIZED DISBURSEMENTS: Category Date Recipient Description $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Amount (7) Total Itemized Disbursements: Page 3 of 3 Revised September 2004A Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.USCourtForms.com RECEIPT AND DISBURSEMENT CATEGORY LIST Receipt Categories 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Alimony Arizona - AFDC Arizona - ATF Arizona - CLS Arizona - DES Cash Court Filing Fees Credit Union Deposit DES/DDD DES/DDD Rental Assistance 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Direct Deposit to Account Distribution from Restricted Funds Final Accounting Fee Inheritance Insurance Benefit Interest Income Miscellaneous Income Payroll Private Pension Refund (other than tax) Reimbursement Disbursement Categories 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Appliances Assessments Attorney's Fees Auto Loan Payment Babysitting Bank Charges Burial Expenses Caregiver Expense Child Expense Cleaning Clothing Court Clerk Filing Fee Court Fees Court Fine Payments Day Program/Day Treatment Deposit Diapers Education - School Expenses Educational Matter Electronics Entertainment Expenses of Sale Fees Furniture Gifts Haircuts/Perms 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. Hobbies/Art Supplies Insurance Payment - Secondary Insurance Premium Insurance Premium - Auto Insurance Premium - Life Laundry Linens Meals/Groceries Medical Expenses Medical - Dental Expenses Medical Eyewear/Exams/Treatment Medical - Massage Therapy Medical - Prescription Drugs Medical - Psychotherapy Medicare Co-Payment Miscellaneous Expense Miscellaneous Payment Mortgage Payment Moving Expense Personal Needs Pet Expenses Pets - Veterinary Expenses Private Pay - Non-ALTCS Recreation Reimbursement 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. Rep Payee Fee Repairs Residential Program Allowance Room and Board Social Security Overpayment Special Olympics SSI Overpayment Storage Charges Subscriptions Summer Camp Taxes - Arizona State Income Taxes - Federal Income Taxes Paid Transfer to Income Only Trust Account Transportation - County Transportation - Gasoline Transportation - Taxi Fares Transportation Fee - Private Transportation Fee - Public Trip Expenses Trip Expenses -- Lodging Utilities Void Check Withdrawal 23. 24. 25. 26. 27. 28. 29. 30. 31. Rental Income Sale - Gain on Sale of Property Social Security Income Supplemental Security Income Tax Refund - Arizona State Tax Refund - Federal Tribal Assistance Veteran's Benefits Revised September 2004 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.USCourtForms.com