NEW YORK STATE DEPARTMENT OF HEALTH
Adult Care Facility/Assisted Living
Adult Care Facility Personal Allowance Summary
PAGE NUMBER
PERSONAL ALLOWANCE
DATE
RECEIPTS
PAYMENTS
RECORDED
RECEIPT FORM
PAYMENT FORM
(Deposits)
(Withdrawals)
(Month/Day/Year) NUMBERS (Deposits) NUMBERS (Withdrawals) Monthly Total Amount Monthly Total Amount
DOH-5196 (DSS-2855) (Revised 7/85, 6/14, 10/15, 12/15)
Current Balance
BROUGHT
FORWARD
$
.