STATE OF NEW YORK



STATE OF NEW YORK

GOVERNOR'S TRAFFIC SAFETY COMMITTEE

STOP-DWI

REPORT OF INCOME AND EXPENDITURES FOR QUARTER 1, 20  _

(JANUARY 1, - MARCH 31, 20  _ )

|      |COUNTY |

INCOME

|A. |CITY, COUNTY AND DISTRICT COURT FINES RECEIVED: |$       |

| |(NET AMOUNT) | |

|B. |JUSTICE COURT FUND CHECK RECEIVED DURING QUARTER 1: |$       |

| |(NET AMOUNT) | |

|C. |OTHER INCOME (*SPECIFY SOURCE BELOW): |$       |

| |TOTAL INCOME RECEIVED DURING THIS QUARTER (LINES A+B+C): |$       |

* SOURCE OF OTHER INCOME: (NOTE: FUNDS ACCUMULATED IN STOP-DWI ACCOUNT FROM PRIOR YEARS SHOULD NOT BE INCLUDED AS "OTHER INCOME")

|      |

EXPENDITURES

| |TOTAL STOP-DWI EXPENDITURES FOR THIS QUARTER: |$       |

|SIGNED: | |DATE: |      |

| |STOP-DWI COORDINATOR | | |

|SIGNED: | |DATE: |      |

| |COUNTY FISCAL OFFICER | | |

PLEASE RETURN COMPLETED AND SIGNED FORM BY June 15, 20  _ TO:

New York State Governor's Traffic Safety Committee

STOP-DWI Program

6 Empire State Plaza - Room 410

Albany, New York 12228

STATE OF NEW YORK

GOVERNOR'S TRAFFIC SAFETY COMMITTEE

STOP-DWI

REPORT OF INCOME AND EXPENDITURES FOR QUARTER 2, 20  _

(APRIL 1, - JUNE 30, 20  _ )

|      |COUNTY |

INCOME

|A. |CITY, COUNTY AND DISTRICT COURT FINES RECEIVED: |$       |

| |(NET AMOUNT) | |

|B. |JUSTICE COURT FUND CHECK RECEIVED DURING QUARTER 2: |$       |

| |(NET AMOUNT) | |

|C. |OTHER INCOME (*SPECIFY SOURCE BELOW): |$       |

| |TOTAL INCOME RECEIVED DURING THIS QUARTER (LINES A+B+C): |$       |

* SOURCE OF OTHER INCOME: (NOTE: FUNDS ACCUMULATED IN STOP-DWI ACCOUNT FROM PRIOR YEARS SHOULD NOT BE INCLUDED AS "OTHER INCOME")

|      |

EXPENDITURES

| |TOTAL STOP-DWI EXPENDITURES FOR THIS QUARTER: |$       |

|SIGNED: | |DATE: |      |

| |STOP-DWI COORDINATOR | | |

|SIGNED: | |DATE: |      |

| |COUNTY FISCAL OFFICER | | |

PLEASE RETURN COMPLETED AND SIGNED FORM BY September 15, 20  _ TO:

New York State Governor's Traffic Safety Committee

STOP-DWI Program

6 Empire State Plaza - Room 410

Albany, New York 12228

STATE OF NEW YORK

GOVERNOR'S TRAFFIC SAFETY COMMITTEE

STOP-DWI

REPORT OF INCOME AND EXPENDITURES FOR QUARTER 3, 20  _

(JULY 1, - SEPTEMBER 30, 20   )

|      |COUNTY |

INCOME

|A. |CITY, COUNTY AND DISTRICT COURT FINES RECEIVED: |$       |

| |(NET AMOUNT) | |

|B. |JUSTICE COURT FUND CHECK RECEIVED DURING QUARTER 3: |$       |

| |(NET AMOUNT) | |

|C. |OTHER INCOME (*SPECIFY SOURCE BELOW): |$       |

| |TOTAL INCOME RECEIVED DURING THIS QUARTER (LINES A+B+C): |$       |

* SOURCE OF OTHER INCOME: (NOTE: FUNDS ACCUMULATED IN STOP-DWI ACCOUNT FROM PRIOR YEARS SHOULD NOT BE INCLUDED AS "OTHER INCOME")

|      |

EXPENDITURES

| |TOTAL STOP-DWI EXPENDITURES FOR THIS QUARTER: |$       |

|SIGNED: | |DATE: |      |

| |STOP-DWI COORDINATOR | | |

|SIGNED: | |DATE: |      |

| |COUNTY FISCAL OFFICER | | |

PLEASE RETURN COMPLETED AND SIGNED FORM BY December 15, 20  __ TO:

New York State Governor's Traffic Safety Committee

STOP-DWI Program

6 Empire State Plaza - Room 410

Albany, New York 12228

STATE OF NEW YORK - GOVERNOR'S TRAFFIC SAFETY COMMITTEE

STOP-DWI REPORT OF INCOME AND EXPENDITURES

QUARTER 4 (OCT. - DEC. 20  _ ) AND ANNUAL REPORT - (JAN. - DEC., 20  _ )

|      |COUNTY |

| |INCOME |QUARTER 4 (OCT-DEC) |ANNUAL |

|A. |CITY, COUNTY AND DISTRICT COURT FINES RECEIVED: (NET AMOUNT) |$       |$       |

|B. |JUSTICE COURT FUND CHECK RECEIVED (NET AMOUNT) |$       |$       |

|C. |OTHER INCOME (*SPECIFY SOURCE BELOW): |$       |$       |

| |TOTAL INCOME RECEIVED DURING THIS QUARTER (LINES A+B+C): |$       |$       |

* SOURCE OF OTHER INCOME: (NOTE: FUNDS ACCUMULATED IN STOP-DWI

ACCOUNT FROM PRIOR YEARS SHOULD NOT BE INCLUDED AS "OTHER INCOME")

|      |

|EXPENDITURES |QUARTER 4 (OCT-DEC) |ANNUAL |

|PERSONAL SERVICES: |$       |$       |

|OTHER THAN PERSONAL SERVICES: |$       |$       |

|TOTAL EXPENDITURES: |$       |$       |

ACTUAL FULL YEAR EXPENDITURES BY PROGRAM COMPONENT

|ENFORCEMENT |$       |

|COURT RELATED |$       |

|PROBATION |$       |

|REHABILITATION |$       |

|P.I. & E. |$       |

|PROGRAM ADMINISTRATION |$       |

|TOTAL (MUST AGREE WITH TOTAL EXPENDITURES ABOVE) |$       |

|*REVENUE (rollover) - ACCOUNT BALANCE ON DEC. 31 20  _ * |$       |

|SIGNED: | |DATE: |      |

| |STOP-DWI COORDINATOR | | |

|SIGNED: | |DATE: |      |

| |COUNTY FISCAL OFFICER | | |

PLEASE RETURN COMPLETED AND SIGNED FORM BY March 30, 20  _ TO:

New York State Governor's Traffic Safety Committee

STOP-DWI Program

6 Empire State Plaza - Room 410

Albany, New York 12228

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