Budget Tool

Cap Choice Kids

* This tool is for estimation of an individual budget and does not constitute an obligation on the part of GT Independence or Cap Choice to fund or authorize services.

Consumer Information

Participant Name:

New/Existing:

CM/Lead Agency Name: DMA Region:

	Begins	Ends	Start Date
Authorization Period:

Include Workers Compensation in Adjusted Rate?

Unallocated Expenses	Unit	Amount	Frequency	Pay Rate	Expense Type	Adjusted Rate	Expected Cost


					Total Unallocated Expenses

# of Full Time Employees:

# of Part Time Employees:

Authorization Sheet - North Carolina

Participant Name: Begin Date: End Date:

Agency:

Authorized Service	Service Code	Unit	Amount	Frequency	Calculated Rate / Unit Rate	Total Funding During Authorization Period


					Total

Employee Monthly Cost:	Total Monthly Cost:	Total Auth Cost:

* This tool is for estimation of an individual budget and does not constitute an obligation on the part of GT Independence or Cap Choice to fund or authorize services.

** Workers Compensation has been rolled into the calculated hourly/unit cost and may not reflect hourly wages paid to employees.

Service Plan Budget - North Carolina

Participant Name: Begin Date: End Date:

Agency:

Expenses	Unit	Amount	Frequency	Calculated Rate / Pay Rate	Expected Cost (auth. Period)


				Total:

_______________________________________________________________________ ______________

signed date

By my signature I acknowledge that I have been given a copy of my budget

* This tool is for estimation of an individual budget and does not constitute an obligation on the part of GT Independence or Cap Choice to fund or authorize services.

** Workers Compensation has been rolled into the calculated hourly/unit cost and may not reflect hourly wages paid to employees.

Save info:

Unallocated Dollars
Total Expected Cost During Authorization Period