Atlantis Health Care Group of Puerto Rico Inc.

Petty Cash Reconciliation Sheet

Month/Year: Octubre 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $131.92

REIMBURSEMENT PAID: $168.08

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

10/11/2021 Ferretería Santana Artículos Planta Física $7.23 $292.77

Artículos para salón comedor
10/21/2021 Econo (café, azúcar, leche) $68.43 $224.34

9/18/2021 Systems Adapter para Laptop Gerente $6.67 $217.67

$217.67

$217.67

$217.67

$217.67

$217.67

$217.67

$217.67

$217.67

$217.67

$217.67

MONTH-END BALANCE: $217.67

TOTAL OF EXPENSES: $82.33

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By: Esther M. Irizarry Vélez

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Septiembre 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $118.74

REIMBURSEMENT PAID: $181.26

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

9/3/2021 Gasolinera Puma Krazy glue $2.22 $297.78

9/3/2021 Mr Special Leche, azúcar, café y filtros $79.56 $218.22

9/8/2021 The Home Depot Area técnica y mantenimiento $86.30 $131.92

$131.92

$131.92

$131.92

$131.92

$131.92

$131.92

$131.92

$131.92

$131.92

$131.92

MONTH-END BALANCE: $131.92

TOTAL OF EXPENSES: $168.08

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By: Esther M. Irizarry Vélez

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Agosto 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $118.74

REIMBURSEMENT PAID: $181.26

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

8/3/2021 Caribbean Lumber Artículos para pintar y montar cuadros en pared $24.64 $275.36

8/3/2021 Caribbean Lumber Rociador para fumigar $14.48 $260.88

8/4/2021 Caribbean Lumber Artículos para Planta Fisica $21.76 $239.12

8/5/2021 Caribbean Lumber Artículos para Planta Fisica $8.58 $230.54

$230.54

$230.54

$230.54

$230.54

$230.54

$230.54

$230.54

$230.54

$230.54

MONTH-END BALANCE: $230.54

TOTAL OF EXPENSES: $69.46

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By: Esther M. Irizarry Vélez

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Julio 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $118.74

REIMBURSEMENT PAID: $181.26

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

7/8/2021 Ferretería Santana llave $3.91 $296.09

7/8/2021 United State Postal Service Servicio postal $8.45 $287.64

7/12/2021 Gasolinera Puma leche y café $10.18 $277.46

Café, vasos, leche, filtros, cremora, azúcar y
7/19/2021 Econo líquido para fregar (salón comedor) $116.11 $161.35

7/29/2021 Gasolinera Puma Hielo para muestras $1.82 $159.53

$159.53

$159.53

$159.53

$159.53

$159.53

$159.53

$159.53

$159.53

MONTH-END BALANCE: $159.53

TOTAL OF EXPENSES: $140.47

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Junio 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $118.74

REIMBURSEMENT PAID: $181.26

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

$300.00

$300.00

$300.00

$300.00

$300.00

$300.00

$300.00

$300.00

$300.00

$300.00

$300.00

$300.00

$300.00

MONTH-END BALANCE: $300.00

TOTAL OF EXPENSES: $0.00

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Mayo 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $0.00

REIMBURSEMENT PAID: $300.00

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

5/6/2021 Ferretería Santana Artículos Planta Fisica $3.33 $296.67

5/14/2021 Plaza del Mercado San Germán Café $25.00 $271.67

5/16/2021 Caribbean Lumber Artículos Planta Fisica $24.03 $247.64

5/17/2021 Mr. Special Arículos para nevera de medicamentos $12.84 $234.80

5/17/2021 Roger Electric Artículos Planta Fisica $14.39 $220.41

5/18/2021 Walgreens Kleenex para la sala de espera $5.58 $214.83

5/22/2021 Pueblo leche y chocolate para área de comedor $42.61 $172.22

5/26/2021 Walmart Relojes de pared $22.61 $149.61

5/26/2021 The Home Depot Artículos Planta Fisica $30.87 $118.74

$118.74

$118.74

$118.74

$118.74

MONTH-END BALANCE: $118.74

TOTAL OF EXPENSES: $181.26

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Abril 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $20.75

REIMBURSEMENT PAID: $279.25

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

4/1/2021 Econo Café, leche y azúcar $73.25 $226.75

4/3/2021 Pueblo Líquido de fregar $8.58 $218.17

4/3/2021 Walmart Bocina $54.64 $163.53

4/9/2021 Caribbean Lumber Corredera (área de almacén) $11.14 $152.39

4/21/2021 United States Postal Service Priority Mail $19.49 $132.90

4/16/2021 National Lumber Artículos Planta Fisica $17.59 $115.31

4/27/2021 The Home Depot Artículos para almacenamiento y limpieza $149.48 -$34.17

4/27/2021 The Home Depot Artículos para almacenamiento y limpieza $11.13 -$45.30

4/29/2021 The Home Depot Artículos para almacenamiento y limpieza $82.20 -$127.50

-$127.50

-$127.50

-$127.50

-$127.50

MONTH-END BALANCE: -$127.50

TOTAL OF EXPENSES: $427.50

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Marzo 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $20.75

REIMBURSEMENT PAID: $279.25

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

3/2/2021 Caribbean Lumber Area Técnica $8.32 $291.68

3/29/2021 Puma café y leche $6.28 $285.40

$285.40

$285.40

$285.40

$285.40

$285.40

$285.40

$285.40

$285.40

$285.40

$285.40

$285.40

MONTH-END BALANCE: $285.40

TOTAL OF EXPENSES: $14.60

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Febrero 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $262.02

REIMBURSEMENT PAID: $37.98

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

Decoración Actividad para pacientes Día de San
2/2/2021 Walgreens Valentin $41.12 $258.88

2/5/2021 Econo Café, leche, cremora y vasos $86.62 $172.26

2/5/2021 Garaje Puma extensión para conexión de termometro $8.54 $163.72

2/5/2021 Office And School Outlet Artículos para boletin boar y agendas $43.78 $119.94

2/20/2021 Walmart Artículos de Oficina $26.69 $93.25

2/18/2021 Office Depot Artículos de Oficina $35.47 $57.78

2/11/2021 Supermercados Pueblo Artículos para el salón comedor $37.03 $20.75

$20.75

$20.75

$20.75

$20.75

$20.75

$20.75

MONTH-END BALANCE: $20.75

TOTAL OF EXPENSES: $279.25

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Enero 2021
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $49.85

REIMBURSEMENT PAID: $250.15

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

1/4/2021 Walmart Agenda y folders $14.59 $285.41

1/28/2021 Marshalls Cover celular y actividad para empleados $23.39 $262.02

$262.02

$262.02

$262.02

$262.02

$262.02

$262.02

$262.02

$262.02

$262.02

$262.02

$262.02

MONTH-END BALANCE: $262.02

TOTAL OF EXPENSES: $37.98

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Diciembre 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $168.00

REIMBURSEMENT PAID: $132.00

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

12/3/2020 Pueblo Café $55.21 $244.79

12/21/2020 Gasolinera Leche $7.88 $236.91

12/21/2020 Pueblo Leche $6.49 $230.42

12/22/2020 Bargain City Articulos Arbol de Navidad $110.04 $120.38

12/30/2020 The Home Depot Planta Física $70.53 $49.85

$49.85

$49.85

$49.85

$49.85

$49.85

$49.85

$49.85

$49.85

MONTH-END BALANCE: $49.85

TOTAL OF EXPENSES: $250.15

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Noviembre 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $143.60

REIMBURSEMENT PAID: $156.40

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

11/11/2020 Puma cartones de leche (4) $8.83 $291.17

11/16/2020 Walmart Pesas para la balanza de la Unidad $8.18 $282.99

11/16/2020 Office Max Bitácora y gomas para borrar $46.48 $236.51

11/16/2020 The Home Depot Artículos Planta Fisica y Salón Comerdor $68.51 $168.00

$168.00

$168.00

$168.00

$168.00

$168.00

$168.00

$168.00

$168.00

$168.00

MONTH-END BALANCE: $168.00

TOTAL OF EXPENSES: $132.00

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Octubre 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $143.02

REIMBURSEMENT PAID: $156.98

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

10/7/202 Pueblo Café y Agua $15.72 $284.28

10/8/2020 Plaza del Mercado Café $25.00 $259.28

10/12/2020 The Print C SG Sticker (Números de MQ) $48.78 $210.50

10/30/2020 Compression Health Care Oxígeno para el Carro de Paro $66.90 $143.60

$143.60

$143.60

$143.60

$143.60

$143.60

$143.60

$143.60

$143.60

$143.60

MONTH-END BALANCE: $143.60

TOTAL OF EXPENSES: $156.40

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date: 11/2/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Septiembre 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $143.02

REIMBURSEMENT PAID: $156.98

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

9/1/2020 Econo Leche $14.87 $285.13

9/16/2020 The Home Depot Buzón de Sugerencias y tape dos caras $89.70 $195.43

9/24/2020 Pueblo Actividad Celebración de Inspección $82.51 $112.92

Utensilios para limpieza de fregadero y área
9/25/2020 Pharmamax comedor $17.08 $95.84

$95.84

$95.84

$95.84

$95.84

$95.84

$95.84

$95.84

$95.84

$95.84

MONTH-END BALANCE: $95.84

TOTAL OF EXPENSES: $204.16

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date: 10/2/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Agosto 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $155.95

REIMBURSEMENT PAID: $144.05

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

7/12/2020 Walmart Artículos para consumo del salón comedor $110.24 $189.76

8/17/2020 Café (10 bolsas) $25.00 $164.76

8/20/2020 Walmart Bolsas para medicamentos (pastillas) $11.50 $153.26

8/26/2020 National Lumber área técnica $5.61 $147.65

8/31/2020 Puma leche $4.63 $143.02

$143.02

$143.02

$143.02

$143.02

$143.02

$143.02

$143.02

$143.02

MONTH-END BALANCE: $143.02

TOTAL OF EXPENSES: $156.98

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date: 9/2/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Julio 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $210.95

REIMBURSEMENT PAID: $89.05

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

7/8/2020 Affidavit Programa NHSN $25.00 $275.00

7/15/2020 Gasolinera Hielo para alimentos donados $8.75 $266.25

7/22/2020 Pulidoras Rental & Janitorial Supply Guantes XL y Large $89.75 $176.50

7/29/2020 Econo Asopao al Personal - Plan de Contingencia $16.61 $159.89

7/31/2020 Gasolinera Leche para café $3.94 $155.95

$155.95

$155.95

$155.95

$155.95

$155.95

$155.95

$155.95

$155.95

MONTH-END BALANCE: $155.95

TOTAL OF EXPENSES: $144.05

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date: 8/13/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Junio 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: -$84.85

REIMBURSEMENT PAID: $384.85

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

6/8/2020 The Home Depot Artículos de Planta Fisica $29.55 $270.45

6/16/2020 Walgreens Café, zúcar y leche $16.71 $253.74

6/27/2020 Pueblo Café, leche, filtros y azúcar $42.79 $210.95

$210.95

$210.95

$210.95

$210.95

$210.95

$210.95

$210.95

$210.95

$210.95

$210.95

MONTH-END BALANCE: $210.95

TOTAL OF EXPENSES: $89.05

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Mayo 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $209.99

REIMBURSEMENT PAID: $90.01

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

Phillips Flat Head Brass Wood Screw, 2 Gal Sprayer and
5/3/2020 The Home Depot Satin Chrome Commercial Grade Kick Down Doorstop $88.74 $211.26

5/6/2020 The Print CSG Banner de Enfermería $35.68 $175.58

3/21/2020 Tiger Direct Wireless Keyboard with touchpad $43.74 $131.84

5/11/2020 Paradise Flowers 45 claveles $46.25 $85.59

5/13/2020 Walmart Café y azúcar $11.33 $74.26

5/15/2020 Office Max Cable Fax $11.47 $62.79

tornillos de pared para cuadros de licencias y
5/20/2020 Walmart permisos $8.64 $54.15

5/20/2020 Office & School Actividad Paciente Mes Renal $8.99 $45.16

5/20/2020 Walgreens Oficina de Gerente y Baños $36.93 $8.23

5/21/2020 Pueblo Actividad Paciente Mes Renal $14.03 -$5.80

5/21/2020 Walmart Agua $8.83 -$14.63

5/23/2020 Mr. Special azúcar, café y leche $37.62 -$52.25

5/26/2020 The Home Depot Planta Fisica $25.36 -$77.61

copias tamaño 11x17 full color Actividad pacientes
5/27/2020 Office & School Mes Renal $7.24 MONTH-END BALANCE: -$84.85

TOTAL OF EXPENSES: $384.85

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date: 5/29/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Abril 2020 - Petty Especial
Facility: San Germán
Amount Approved: $1,000.00

BALANCE

PRIOR BALANCE: $1,000.00

REIMBURSEMENT PAID:

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

MONTH-END BALANCE: $1,000.00

TOTAL OF EXPENSES: $0.00

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date: 5/4/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Abril 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $169.41

REIMBURSEMENT PAID: $130.59

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

4/6/2020 Supermercado Napo Vélez Clorox 16 galones $38.24 $261.76

4/9/2020 Walgreens Master Covered Pallocks $17.83 $243.93

4/15/2020 Walgreens cajas plásticas para el control de mascarillas $13.88 $230.05

4/17/2020 Mr. Special azúcar y café $11.95 $218.10

4/22/2020 Walgreens artículos para ajustar "faceshields" $8.11 $209.99

$209.99

$209.99

$209.99

$209.99

$209.99

$209.99

$209.99

$209.99

MONTH-END BALANCE: $209.99

TOTAL OF EXPENSES: $90.01

AMOUNT FOR REIMBURSEMENT:

Prepared By: Sarid M. Segarra Rodríguez Certified By:

Date: 5/4/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Marzo 2020 - Petty Especial
Facility: San Germán
Amount Approved: $1,000.00

BALANCE

PRIOR BALANCE: $1,000.00

REIMBURSEMENT PAID:

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $1,000.00

3/30/2020 Walmart Compra de alimentos para emergencia $15.09 $984.91

$984.91

$984.91

$984.91

$984.91

$984.91

$984.91

$984.91

$984.91

$984.91

$984.91

$984.91

$984.91

MONTH-END BALANCE: $984.91

TOTAL OF EXPENSES: $15.09

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Marzo 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $104.33

REIMBURSEMENT PAID: $195.67

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

2/19/2020 Econo Utensilios para el Comedor $7.67 $292.33

3/9/2020 Ferretería Santana área técnico biomédico $15.60 $276.73

3/14/2020 Walgreens $37.03 $239.70

3/15/2020 Walmart Utensilios para la Unidad y área comedor $67.54 $172.16

3/27/2020 USPS sellos para cartas a pacientes (facturacón) $2.75 $169.41

$169.41

$169.41

$169.41

$169.41

$169.41

$169.41

$169.41

$169.41

MONTH-END BALANCE: $169.41

TOTAL OF EXPENSES: $130.59

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Febrero 2020 - Petty Especial
Facility: San Germán
Amount Approved: $1,000.00

BALANCE

PRIOR BALANCE: $824.39

REIMBURSEMENT PAID: $175.61

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

$1,000.00

MONTH-END BALANCE: $1,000.00

TOTAL OF EXPENSES: $0.00

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date: 3/9/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Febrero 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $254.60

REIMBURSEMENT PAID: $45.40

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

2/2/2020 Bargain City Artículos actividad para pacientes de San Valentin $7.73 $292.27

2/5/2020 Econo Artículos para Salón Comedor $87.49 $204.78

2/5/2020 National Lumber Artículos actividad para pacientes de San Valentin $15.03 $189.75

2/11/2020 Ferretería Santana Artículos Planta Fisica y área del Técnico $6.68 $183.07

2/11/2020 Caribbean Lumber Artículos Planta Fisica y área del Técnico $8.11 $174.96

2/17/2020 Caribbean Lumber Artículos Planta Fisica y área del Técnico $6.77 $168.19

2/17/2020 Home Depot Artículos Planta Fisica y área del Técnico $12.80 $155.39

2/19/2020 Gasolinera Puma azúcar $2.00 $153.39

2/26/2020 Pueblo Alimentos para reunón de Junta de Gobierno $11.26 $142.13

2/27/2020 Puma café y leche $15.30 $126.83

Materiales para Actividad de Pacientes San
2/10/2020 Office School Outlet Valentin $8.88 $117.95
Materiales para Actividad de Pacientes San
2/12/2020 Econo Valentin $6.99 $110.96
Materiales para Actividad de Pacientes San
2/15/2020 Lapiz Papel School Supply Valentin $6.63 $104.33

MONTH-END BALANCE: $104.33

TOTAL OF EXPENSES: $195.67

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date: 3/10/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Enero 2020 - Petty Especial
Facility: San Germán
Amount Approved: $1,000.00

BALANCE

PRIOR BALANCE: $1,000.00

REIMBURSEMENT PAID:

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $1,000.00

1/14/2020 Mr. Special Botellas de Agua $8.06 $991.94

1/14/2020 Mr. Special Suministro para Emergencia $167.55 $824.39

$824.39

$824.39

$824.39

$824.39

$824.39

$824.39

$824.39

$824.39

$824.39

$824.39

$824.39

MONTH-END BALANCE: $824.39

TOTAL OF EXPENSES: $175.61

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date: 2/7/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Enero 2020
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $218.42

REIMBURSEMENT PAID: $81.58

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

1/8/2020 Puma café $7.86 $292.14

1/9/2020 Caribbean Lumber San Germán Agua y manga de lavadora $14.27 $277.87

1/30/2020 Mr. Special Café y azúcar $23.27 $254.60

$254.60

$254.60

$254.60

$254.60

$254.60

$254.60

$254.60

$254.60

$254.60

$254.60

MONTH-END BALANCE: $254.60

TOTAL OF EXPENSES: $45.40

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date: 2/7/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Diciembre 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $88.61

REIMBURSEMENT PAID: $211.39

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

12/11/2019 The Home Depot $138.23 $161.77

12/17/2019 Walmart $80.19 $81.58

$81.58

$81.58

$81.58

$81.58

$81.58

$81.58

$81.58

$81.58

$81.58

$81.58

$81.58

MONTH-END BALANCE: $81.58

TOTAL OF EXPENSES: $218.42

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date: 1/14/2020

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Noviembre 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $88.61

REIMBURSEMENT PAID: $211.39

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

11/11/2019 Me Salve Decoración de Navidad Unidad $35.66 $264.34

11/11/2019 Always 99 Artículos Sala de Espera y Pasillos $32.31 $232.03

11/20/2019 Puma Azúcar y leche $3.13 $228.90

11/19/2019 Supermercado Pueblo Sarten Electrico para el área del comedor $22.29 $206.61

11/22/2019 Ferretería Santana Artículos área técnica Planta Física $14.99 $191.62

11/25/2019 Econo Artículos para el Pantry $49.34 $142.28

$142.28

$142.28

$142.28

$142.28

$142.28

$142.28

$142.28

MONTH-END BALANCE: $142.28

TOTAL OF EXPENSES: $157.72

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date: 12/11/2019

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Octubre 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $57.60

REIMBURSEMENT PAID: $242.40

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

10/2/2019 Walgreens leche, café y azúcar $10.03 $289.97

10/13/2019 Econo Artículos "pantry" $53.80 $236.17

10/22/2019 Caribbean Lumber Artículos área técnica $18.94 $217.23

10/26/2019 Tienda de Souvenirs Tazas de Café para Pantry $11.10 $206.13

10/27/2019 The Home Depot Artículos "pantry" $72.99 $133.14

10/29/2019 The Home Depot Artículos "pantry" $8.33 $124.81

10/30/2019 Puma leche y café $19.66 $105.15

10/23/2019 Pueblo Reunión Junta Gobierno $10.04 $95.11

9/19/2019 Puma leche para café $2.24 $92.87

9/29/2019 Puma azúcar y café $4.26 $88.61

$88.61

$88.61

$88.61

MONTH-END BALANCE: $88.61

TOTAL OF EXPENSES: $211.39

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Septiembre 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $41.17

REIMBURSEMENT PAID: $258.83

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

9/4/2019 Puma Leche $1.95 $298.05

9/8/2019 Panadería Café $2.27 $295.78

9/8/2019 Caribbean Lumber San Germán Materiales Planta Física $16.68 $279.10

9/8/2019 Walmart Artículos "pantry" $39.40 $239.70

9/9/2019 Jani Clean Líquido para Limpieza $31.22 $208.48

9/7/2019 The Home Depot Cafetera y artículos de limpieza de Unidad $146.62 $61.86

9/18/2019 Puma Café y Azúcar $4.26 $57.60

$57.60

$57.60

$57.60

$57.60

$57.60

$57.60

MONTH-END BALANCE: $57.60

TOTAL OF EXPENSES: $242.40

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Agosto (2) 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $76.17

REIMBURSEMENT PAID: $223.83

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

8/7/2019 The Home Depot Herramientas $32.62 $267.38

8/20/2019 Garage Total Carlos Guilloty Azúcar y Leche $4.24 $263.14

8/20/2019 Walmart Artículos Unidad $128.12 $135.02

8/17/2019 The Home Depot Artículos área Técnica $47.29 $87.73

8/28/2019 Pandería Desayuno Staff Plan de Contingencia $26.85 $60.88

8/7/2019 Puma Azúcar $2.01 $58.87

8/7/2019 Puma Azúcar y Lubricante para Sillas de Diálisis $7.01 $51.86

8/15/2019 Puma Azúcar $2.01 $49.85

8/19/2019 Puma Café $8.68 $41.17

$41.17

$41.17

$41.17

$41.17

MONTH-END BALANCE: $41.17

TOTAL OF EXPENSES: $258.83

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Agosto 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $95.68

REIMBURSEMENT PAID: $204.32

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

8/1/2019 Walgreens libreta $10.99 $289.01

8/3/2019 The Home Depot 5pc pliers set $14.45 $274.56

8/3/2019 The Home Depot Artículos Planta Fisica y área de Técnico Biomédico $138.63 $135.93

8/3/2019 The Home Depot Artículos Planta Fisica y área de Técnico Biomédico $11.11 $124.82

8/3/2019 The Home Depot Artículos Planta Fisica y área de Técnico Biomédico $6.65 $118.17

8/3/2019 The Home Depot Artículos Planta Fisica y área de Técnico Biomédico $22.26 $95.91

8/5/2019 Puma Azúcar, café, leche y filtros $19.74 $76.17

$76.17

$76.17

$76.17

$76.17

$76.17

$76.17

MONTH-END BALANCE: $76.17

TOTAL OF EXPENSES: $223.83

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Julio 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $218.29

REIMBURSEMENT PAID: $81.71

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

7/1/2019 Puma Artículos para Café $10.01 $289.99

7/3/2019 Puma Artículos para Café $9.87 $280.12

7/9/2019 Puma Artículos para Café $5.38 $274.74

7/9/2019 The Home Depot Artículos para limpieza y área técnica $67.28 $207.46

7/9/2019 The Home Depot Artículos para limpieza y área técnica $2.91 $204.55

7/12/2019 El Meson Reunión QAPI $13.05 $191.50

7/12/2019 Econo Artículos "pantry" y QAPI $21.21 $170.29

7/16/2019 Puma Café $4.50 $165.79

7/16/2019 Smart Dollar Hooks $8.37 $157.42

7/19/2019 Puma Café y Leche $7.87 $149.55

7/19/2019 Puma Azúcar $2.00 $147.55

7/20/2019 The Home Depot Artículos de Limpieza y área Técnica $33.27 $114.28

7/26/2019 Puma Café, azúcar y leche $17.28 $97.00

7/29/2019 Puma filtros para café $1.32 MONTH-END BALANCE: $95.68

TOTAL OF EXPENSES: $204.32

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Junio 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $176.69

REIMBURSEMENT PAID: $123.31

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

6/14/2019 Puma leche, café y azúcar $8.52 $291.48

6/20/2019 Puma leche, café y azúcar $17.90 $273.58

6/21/2019 Puma Aceite para exterior de máquinas $4.45 $269.13

6/26/2019 Dolphins Rental Articulos Decoración Sala de Espera $25.61 $243.52

6/28/2019 Econo Reunión $25.23 $218.29

$218.29

$218.29

$218.29

$218.29

$218.29

$218.29

$218.29

$218.29

MONTH-END BALANCE: $218.29

TOTAL OF EXPENSES: $81.71

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Mayo 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $196.00

REIMBURSEMENT PAID: $104.00

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

5/1/2019 Puma café $2.25 $297.75

5/3/2019 Puma café $2.25 $295.50

5/6/2019 Puma Leche y café $10.75 $284.75

5/9/2019 Puma Lubricante para bútacas $4.45 $280.30

5/10/2019 Puma café $2.25 $278.05

5/15/2019 Puma café $2.25 $275.80

5/16/2019 Puma leche, café y azúcar $6.00 $269.80

Agua, Azucar, Cremora, Vasos para café, té,
5/17/2019 Econo chocolater cortes, leche y café $77.63 $192.17

5/21/2019 Dophin Rental Decoración Sala de Espera $15.48 $176.69

$176.69

$176.69

$176.69

$176.69

MONTH-END BALANCE: $176.69

TOTAL OF EXPENSES: $123.31

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Abril 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $150.07

REIMBURSEMENT PAID: $149.93

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

4/1/2019 Walgreens USB $11.14 $288.86

4/5/2019 Pep boys Paños para limpieza y aceite para lubricar bútacas $23.39 $265.47

4/7/2019 Walmart Bolsas para Medicamentos (Pastillas) $6.91 $258.56

4/22/2019 Puma café $9.00 $249.56

4/22/2019 Econo clorox $36.24 $213.32

4/25/2019 USPS Envío de paquete $9.30 $204.02

4/29/2019 Puma café y azúcar $8.02 $196.00

$196.00

$196.00

$196.00

$196.00

$196.00

$196.00

MONTH-END BALANCE: $196.00

TOTAL OF EXPENSES: $104.00

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Marzo 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $102.95

REIMBURSEMENT PAID: $197.05

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

Café, Azúcar, Cajas plásticas, cuch medir, Cremora,
3/3/2019 Walmart Leche, Vasos y Cucharas. $45.81 $254.19

3/6/2019 Ferreteria Santana Kit Delta $5.56 $248.63

3/6/2019 Ferreteria Santana Llave de pase y expansiones $10.79 $237.84

3/7/2019 Pep Boys 5V electronic 3PK $6.68 $231.16

3/15/2019 La Casa de los Tornillos Pan Head y Flat Washer $6.06 $225.10

3/21/2019 Puma Filtros de Café $1.17 $223.93

3/26/2019 Puma Café Rico y Azúcar $7.12 $216.81

3/27/2019 Ferreteria Santana área técnica $6.12 $210.69

3/29/2019 Econo Artículos para Salón Comedor $60.62 $150.07

$150.07

$150.07

$150.07

$150.07

MONTH-END BALANCE: $150.07

TOTAL OF EXPENSES: $149.93

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: FEBRERO 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $99.79

REIMBURSEMENT PAID: $200.21

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

2/4/2019 Puma Lubricante área Técnica $8.90 $291.10

2/4/2019 Office & School Outlet Papel Blanco y Materiales Actividad Pacientes TS $14.47 $276.63

2/4/2019 Amazon Agendas $31.36 $245.27

2/5/2019 Walmart Micro SD Card $15.08 $230.19

2/6/2019 Econo Cloro $8.43 $221.76

2/12/2019 Office & School Outlet Cartulina $2.23 $219.53

2/12/2019 Mary Telas Velcro $2.79 $216.74

2/13/2019 Walgreens Cinta $4.45 $212.29

2/7/2019 Puma Leche, filtros, azucar, café $14.62 $197.67

2/5/2019 Walgreens Papel para imprimir $13.35 $184.32

2/18/2019 Econo Vasos, café, leche, azucar, liquido para fregar. $68.02 $116.30

2/21/2019 Ferreteria Santana Copias Llaves $3.35 $112.95

2/22/2019 Electronic Parts Bat Clip $10.00 $102.95

MONTH-END BALANCE: $102.95

TOTAL OF EXPENSES: $197.05

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: ENERO 2019
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $95.93

REIMBURSEMENT PAID: $204.07

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

1/9/2019 Puma Café, azúcar y leche $19.11 $280.89

1/16/2019 Puma Café $4.34 $276.55

1/4/2019 Home Depot Plastic Storage $16.93 $259.62

1/18/2019 US Postal Service Priority Mail $12.90 $246.72

1/21/2019 Ferretería Santana Artículos para Planta Fisica $9.56 $237.16

1/24/2019 Puma Café, vasos y azúcar $10.31 $226.85

1/18/2019 Puma Leche, café y azúcar $17.87 $208.98

1/24/2019 Econo Bolsas $0.33 $208.65

Café, 7 up, picadera e hielo
1/24/2019 Econo Educativa a Estudiantes RUM $27.35 $181.30

1/28/2019 Autozone Llave (articulo de Planta Fisica) $21.17 $160.13

1/28/2019 Pepboys Kit de Herramientas (articulo de Planta Fisica) $32.31 $127.82

1/29/2019 Office & School Outlet Papel Blanco $16.73 $111.09

1/31/2019 Puma Café y azúcar $11.30 $99.79

MONTH-END BALANCE: $99.79

TOTAL OF EXPENSES: $200.21

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Noviembre/Diciembre 2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $126.14

REIMBURSEMENT PAID: $173.86

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

11/12/2018 Kmart Articulos de Navidad para Decoración $19.64 $280.36

11/12/2018 Econo Manteles para Decoración $2.88 $277.48

11/19/2018 Econo Articulos para Limpieza y Café $41.56 $235.92

11/28/2018 US Postal Service sello $0.50 $235.42

11/30/2018 Walgreens Bolletin Board $25.61 $209.81

12/7/2018 Puma Café, leche, azúcar $12.69 $197.12

12/10/2018 Puma Café, leche, azúcar $5.85 $191.27

12/11/2018 Puma Café, leche, azúcar $8.10 $183.17

12/12/2018 Supermercado Tolin Vasos para café $5.29 $177.88

12/12/2018 Office & School Outlet Papel para Invitaciones $15.15 $162.73

12/12/2018 Econo Café, leche, azúcar, filtros $44.59 $118.14

12/17/2018 Kmart Artículos Planta Física $4.05 $114.09

12/20/2018 National Lumber Artículos Planta Física $8.17 $105.92

12/30/2018 Walgreens Libreta para Apuntes $9.99 MONTH-END BALANCE: $95.93

TOTAL OF EXPENSES: $204.07

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Octubre/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $151.61

REIMBURSEMENT PAID: $148.39

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

10/1/2018 Puma Café $4.50 $295.50

10/4/2018 Manger Luis Ronda Area Técnica $11.06 $284.44

10/5/2018 Super Farmacia Mayi Termometro $4.26 $280.18

10/5/2018 Puma Café $2.25 $277.93

10/9/2018 Puma Café $2.25 $275.68

10/11/2018 Puma Café $3.19 $272.49

10/15/2018 Puma Café $2.25 $270.24

10/16/2018 Puma Café y Azúcar $4.60 $265.64

10/18/2018 Puma Café $2.25 $263.39

10/8/2018 Office Max Carton Paper $21.39 $242.00

10/26/2018 Puma Café $4.50 $237.50

Artículos para el Salón Comedor (café, vasos,

10/30/2018 Walmart azúcar, cremora, café, tostadora y plancha) $111.36 $126.14

$126.14

MONTH-END BALANCE: $126.14

TOTAL OF EXPENSES: $173.86

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:
Form: ACT 101-1 (Rev. 11/15/2016)
 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Septiembre/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $204.04

REIMBURSEMENT PAID: $95.96

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

9/4/118 Walgreens Pendrive y Café $16.03 $283.97

9/11/2018 Econo Artículos para café $37.58 $246.39

9/13/2018 Ferretería Santana Area Técnica $8.81 $237.58

9/21/2018 Caribbean Lumber San Germán Area Técnica $57.97 $179.61

9/28/2018 West Point Oxigeno $28.00 $151.61

$151.61

$151.61

$151.61

$151.61

$151.61

$151.61

$151.61

$151.61

MONTH-END BALANCE: $151.61

TOTAL OF EXPENSES: $148.39

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Agosto/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $216.15

REIMBURSEMENT PAID: $83.85

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

8/8/2018 Econo leche, leche, café y azúcar $50.27 $249.73

8/22/2018 USPS Postal Carta certificada $13.45 $236.28

8/27/2018 Caribbean Lumber San Germán Artículos del área médica $8.91 $227.37

8/28/2018 Puma leche y café $8.48 $218.89

8/30/2018 Puma leche y café $14.85 $204.04

$204.04

$204.04

$204.04

$204.04

$204.04

$204.04

$204.04

$204.04

MONTH-END BALANCE: $204.04

TOTAL OF EXPENSES: $95.96

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: JULIO/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $151.82

REIMBURSEMENT PAID: $148.18

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

7/6/2018 Kmart bolsas para laminar y clorox $42.27 $257.73

7/10/2018 Puma leche, café y azúcar $12.35 $245.38

7/31/201 West Point Oxígeno $23.00 $222.38

7/31/2018 Panadería Azúcar $1.74 $220.64

7/31/2018 Panadería Café $4.49 $216.15

$216.15

$216.15

$216.15

$216.15

$216.15

$216.15

$216.15

$216.15

MONTH-END BALANCE: $216.15

TOTAL OF EXPENSES: $83.85

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: JUNIO/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $61.32

REIMBURSEMENT PAID: $238.68

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

6/4/2018 Puma Leche y Café $4.44 $295.56

6/4/2018 Puma Leche $1.95 $293.61

6/4/2018 Walmart Artículos de la Unidad $32.31 $261.30

6/5/2018 Puma Leche $2.50 $258.80

6/5/2018 Caribbean Lumber San Germán Artículos área técnica $8.59 $250.21

6/6/2018 Walgreens Café $2.27 $247.94

6/5/2018 Always 99. Vasos para medicamentos $6.72 $241.22

6/8/2018 Puma Café Yaucono $3.19 $238.03

6/8/2018 Garage Total Carlos Guilloty Azúcar

$2.89 $235.14

6/11/2018 Puma Leche y Café $5.75 $229.39

6/18/2018 Puma Café, Azúcar y Leche $7.94 $221.45

6/19/2018 Jardínes de Flamboyan Saco de Tierra Grande $9.00 $212.45

Agua, café, azucar, leche, vasos y liquido para
6/25/2018 Econo fregar $54.51 $157.94

6/29/2018 Auto Zone WD-40 $6.12 MONTH-END BALANCE: $151.82

TOTAL OF EXPENSES: $148.18

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: MAYO/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $129.96

REIMBURSEMENT PAID: $170.04

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

5/1/2018 Walmart Artículos para área de tratamiento $85.39 $214.61

5/7/2018 Puma Artículos de Limpieza $3.10 $211.51

5/15/2018 Econo Artículos para el área de merendar $45.73 $165.78

5/15/2018 Walgreens Artículos de Limpieza $12.21 $153.57

5/17/2018 Supermercado Napo Vélez Artículos para área de merendar $7.75 $145.82

5/1/2018 Puma Leche $1.53 $144.29

Mesa Domino
5/23/118 Pueblo área Sala de Espera $36.78 $107.51

5/25/2018 The Home Depot Artículos de Limpieza $5.49 $102.02

Domino
5/25/2018 Walmart
Artículos Sala de Espera
$5.53 $96.49

5/28/2018 Puma 3 Leche, azúcar y café $7.46 $89.03

5/30/2018 Puma Café $4.34 $84.69

5/17/2018 Ferretería Santana Artículos área técnica $23.37 $61.32

$61.32

MONTH-END BALANCE: $61.32

TOTAL OF EXPENSES: $238.68

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: ABRIL/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $217.40

REIMBURSEMENT PAID: $82.60

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

4/4/2018 Puma Café y Leche $6.84 $293.16

4/9/2018 Puma Café $2.25 $290.91

4/9/2018 Puma Azúcar $1.87 $289.04

4/12/2018 Puma Azúcar. Leche y Café $7.46 $281.58

4/13/2018 Kmart área técnica $13.93 $267.65

4/13/2018 Puma Vasos y Café $4.52 $263.13

4/13/2018 USPS Carta Certificada $20.85 $242.28

4/18/2018 Puma Café y Azúcar $8.46 $233.82

4/23/2018 Puma Café y Azúcar $6.21 $227.61

4/24/2018 Kmart área técnica $64.13 $163.48

4/25/2018 Puma Café $4.34 $159.14

4/25/2018 Puma Leche $1.25 $157.89

4/26/2018 Puma Café, Leche y Azúcar $7.46 $150.43

4/30/2018 Puma Café, Leche y Azúcar $20.47 MONTH-END BALANCE: $129.96

TOTAL OF EXPENSES: $170.04

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: MARZO/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $209.52

REIMBURSEMENT PAID: $90.48

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

3/1/2018 Farmacia Martin agua esteril (medicamento) $19.50 $280.50

3/1/2018 Walgreens café $4.64 $275.86

3/8/2018 Puma café y filtros $10.00 $265.86

3/8/2018 Walgreens azúcar $3.35 $262.51

3/8/2018 Always 99 Artículos boletín boar TS y Dietista $11.04 $251.47

3/8/2018 Always 99 Artículos boletín boar TS y Dietista $1.66 $249.81

3/14/2018 Puma Café $4.34 $245.47

3/15/2018 Walgreens Walgreens Manual Blood Pressure Kit $20.61 $224.86

3/27/2018 Puma Azúcar, leche y café $7.46 $217.40

$217.40

$217.40

$217.40

$217.40

MONTH-END BALANCE: $217.40

TOTAL OF EXPENSES: $82.60

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: FEBRERO/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $90.22

REIMBURSEMENT PAID: $209.78

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

2/1/2018 Ferretería Santana área técnica $21.17 $278.83

2/5/2018 Puma leche, azúcar y café $7.53 $271.30

2/7/2018 Econo leche, azúcar y café $12.39 $258.91

2/12/2018 Puma leche y café $10.00 $248.91

2/14/2018 Puma café $4.34 $244.57

2/19/2018 Puma leche $2.65 $241.92

2/22/2018 Puma café $4.34 $237.58

2/22/2018 Puma leche y azúcar $4.52 $233.06

2/26/2018 Puma leche y café $13.99 $219.07

2/26/2018 Puma leche $1.47 $217.60

2/28/2018 Puma azúcar y café $8.08 $209.52

$209.52

$209.52

MONTH-END BALANCE: $209.52

TOTAL OF EXPENSES: $90.48

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: ENERO/2018
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $261.44

REIMBURSEMENT PAID: $38.56

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

1/2/2018 Puma café $4.34 $295.66

1/5/2018 Puma Leche y Azúcar $3.26 $292.40

1/9/2018 Puma Azúcar, café y leche $6.31 $286.09

1/14/2018 Puma Deagreaser $3.91 $282.18

1/15/2018 Puma Leche $1.25 $280.93

Ttarjeta Prepagada, Filtros Café, Leche, Azúcar
1/24/2018 Puma Splenda y Café $10.23 $270.70

1/25/2018 Puma café $2.25 $268.45

1/26/2018 Office & School Outlet Materiales para Boletin Board de Nutrición $37.67 $230.78

1/30/2018 Metropolitan Lumber Cerradura de Puerta $11.14 $219.64

1/30/2018 Autozone Flashlight $25.63 $194.01

1/31/2018 Metropolitan Lumber área técinica $78.01 $116.00

1/31/2018 Ferretería Santana área técinica $2.51 $113.49

1/31/2018 Puma café $4.34 $109.15

1/31/2018 Pep Boys área técinica $18.93 MONTH-END BALANCE: $90.22

TOTAL OF EXPENSES: $209.78

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year:
Facility:
Amount Approved:

BALANCE

PRIOR BALANCE:

REIMBURSEMENT PAID:

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

MONTH-END BALANCE: $0.00

TOTAL OF EXPENSES: $0.00

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Enero/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $126.47

REIMBURSEMENT PAID: $173.53

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

1/4/2017 Puma Café $2.25 $297.75

1/5/2017 Ferretería Santana Copia Llave $6.69 $291.06

1/10/2017 Walgreens pen drive $17.83 $273.23

1/11/2017 Sam's Cremora y Café Lata $20.36 $252.87

1/11/2017 Always 99 Vasos para café $2.64 $250.23

1/18/2017 Econo Vasos para café y galletas $11.11 $239.12

1/20/2017 Puma Leche para café y azúcar $3.19 $235.93

Copia Llave, Presintas, tape doble, brocha para
1/20/2017 Ferretería Santana pintar y pintura negra $28.28 $207.65

1/23/2017 Econo Desayuno reunión TS $5.05 $202.60

1/23/2017 Econo Desayuno reunión TS $4.52 $198.08

1/23/2017 Royvan's Café Desayuno reunión TS $10.00 $188.08

1/23/2017 Doña Flor Almuerzo (Reunión TS) $30.00 $158.08

1/26/2017 Econo Crema café, cremora, vasos y azúcar $23.64 $134.44

1/27/2017 Metropolitan Lumber San Germán Cables $8.63 MONTH-END BALANCE: $125.81

TOTAL OF EXPENSES: $174.19

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Febrero/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $125.81

REIMBURSEMENT PAID: $174.19

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

2/1/2017 Office & School Outlet Poster Markers (Boletin board Nutrition) $5.55 $294.45

2/1/2017 Office & School Outlet Artículos para Boletin board Nutrition $20.03 $274.42

2/6/2017 Mr. Special Agua oxígenada y Panadol $4.44 $269.98

2/6/2017 USPS Sello para carta $0.49 $269.49

2/9/2017 Metropolitan Lumber San Germán Hillman Lock Washer y Machine Screw $11.94 $257.55

2/20/2017 Metropolitan Lumber San Germán USB Cable 6FT $3.00 $254.55

2/22/2017 West Point Oxígeno (recarga) $22.00 $232.55

2/22/2017 USPS Carta Certificada y Acuse de Recibo $6.59 $225.96

2/22/2017 Kmart Café $13.91 $212.05

2/28/2017 Walgreens Calendarios 2017 $17.24 $194.81

2/28/2017 National Microondas $111.49 $83.32

2/28/2017 Sams café y azucar $21.78 $61.54

$61.54

MONTH-END BALANCE: $61.54

TOTAL OF EXPENSES: $238.46

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Marzo/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $61.54

REIMBURSEMENT PAID: $238.46

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

3/3/2017 Gasolinera PUMA Alcohol $1.78 $298.22

Carta Certificadas con Acuses de Recibo
3/3/2017 USPS (Credenciales a MD) $20.68 $277.54

3/15/2017 Gasolinera PUMA Café y Leche $4.32 $273.22

3/14/2017 Ferretería Santana Pintura y Ajax $12.13 $261.09

3/14/2017 Metropolitan Lumber Masilla, brocha y esponja $5.07 $256.02

3/14/2017 West Point Oxígeno $22.00 $234.02

3/21/2017 Panadería Mi Postre Café y Leche $5.99 $228.03

3/23/2017 USPS Libreta de Sellos $6.86 $221.17

3/30/2017 Econo Café. Azúcar, vasos, filtros y cremora $18.30 $202.87

$202.87

$202.87

$202.87

$202.87

MONTH-END BALANCE: $202.87

TOTAL OF EXPENSES: $97.13

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Abril/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $202.87

REIMBURSEMENT PAID: $97.13

DATE PROVIDER DESCRIPTION OF EXPENSE

Materiales para Departamento Técnico Biomédico
AMOUNT BEGINNING BALANCE: $300.00
(Técnico Regional Joel Hernández entregro recibos en
3/30/2017 National Lumber el mes de abril) $8.43 $291.57

4/5/2017 Always 99 Materiales para los Banners de Nutrición $16.64 $274.93

4/5/2017 Office School Outlet Materiales para los Banners de Nutrición $31.09 $243.84

4/13/2017 Econo Café, azúcar y agua $9.54 $234.30

4/20/2017 Econo Materiales para educativa a pacientes (Nutrición) $19.08 $215.22

4/26/2017 Puma Café $2.25 $212.97

4/30/2017 Econo Café, azúcar, removedores y vasos $18.37 $194.60

$194.60

$194.60

$194.60

$194.60

$194.60

$194.60

MONTH-END BALANCE: $194.60

TOTAL OF EXPENSES: $105.40

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Mayo/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $194.60

REIMBURSEMENT PAID: $105.40

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

5/8/2017 Walmart Artículos para la Unidad $102.79 $197.21

5/9/2017 Ferretería Santana Artículos para Planta Fisica $26.58 $170.63

5/9/2017 Puma (Gasolinera) Azúcar $3.74 $166.89

5/11/2017 Metropolitan Lumber Artículos Planta Fisica $18.14 $148.75

5/11/2017 Econo Café, cremora y azúcar $23.01 $125.74

5/18/2017 Farmacia Sagrado Corazón Alcohol $4.00 $121.74

5/23/2017 Puma (Gasolinera) Café y Azúcar $6.37 $115.37

5/24/2017 Walgreens Papel para Certificado $6.46 $108.91

5/25/2017 Puma (Gasolinera) Café y Azúcar $6.37 $102.54

$102.54

$102.54

$102.54

$102.54

MONTH-END BALANCE: $102.54

TOTAL OF EXPENSES: $197.46

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Mayo/2017
Facility: San Germán
Amount Approved: $380.00

BALANCE

PRIOR BALANCE: $380.00

REIMBURSEMENT PAID:

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $380.00

5/11/2017 Walmart Actividad Semana de Enfermería $38.47 $341.53

5/11/2017 Econo Actividad Semana de Enfermería $36.82 $304.71

5/12/2017 Puma Actividad Semana de Enfermería $6.12 $298.59

5/12/2017 El Mesón Actividad Semana de Enfermería $52.18 $246.41

5/12/2017 Walgreens Actividad Semana de Enfermería $26.32 $220.09

5/12/2017 Econo Actividad Semana de Enfermería $17.03 $203.06

5/12/2017 Charr&Mar Actividad Semana de Enfermería $118.85 $84.21

5/12/2017 Volcanos Pizza Actividad Semana de Enfermería $39.99 $44.22

5/18/2017 Always 99 Actividad Semana de Enfermería $4.97 $39.25

5/19/2017 Econo Actividad Semana de Enfermería $1.52 $37.73

5/19/2017 Econo Actividad Semana de Enfermería $38.50 -$0.77

-$0.77

-$0.77

MONTH-END BALANCE: -$0.77

TOTAL OF EXPENSES: $380.77

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Junio/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $102.54

REIMBURSEMENT PAID: $197.46

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

6/2/2017 Puma Café, leche y azúcar $6.38 $293.62

6/6/6/17 Puma Café $18.00 $275.62

6/16/2017 El Mesón Desayuno Reunión QAPI $13.05 $262.57

6/16/2017 Econo Azúcar, Agua y Vasos para Café $7.37 $255.20

6/23/2017 Metropolitan Lumber Area Tecnica (te pvc y cap) $2.16 $253.04

6/23/2017 USPS Carta Certifiada y Acuse de Recibo $7.29 $245.75

6/27/2017 Puma Café, Azúcar y Leche $5.29 $240.46

6/27/2017 Ferretería Santana Area Tecnica $13.36

6/28/2017 USPS Carta Certifiada y Acuse de Recibo $13.18

6/29/2017 Puma Café y Leche $5.82 $234.64

6/30/2017 Puma Café, leche y azúcar $12.50 $222.14

$222.14

$222.14

$222.14

$222.14

MONTH-END BALANCE: $222.14

TOTAL OF EXPENSES: $104.40

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Julio/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $195.60

REIMBURSEMENT PAID: $104.40

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

7/5/2017 Puma Leche y Filtros para Café $2.64 $297.36

7/7/2017 Puma Leche y Azúcar para Café $3.19 $294.17

Artículos para Café (vasos, café, azúcar ,
7/11/2017 Econo agitadores y agua) $24.73 $269.44

7/18/2017 Econo Café, azúcar y cremora $16.03 $253.41

7/26/2017 Puma Leche $3.98 $249.43

$249.43

$249.43

$249.43

$249.43

$249.43

$249.43

$249.43

$249.43

MONTH-END BALANCE: $249.43

TOTAL OF EXPENSES: $50.57

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Agosto/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $249.43

REIMBURSEMENT PAID: $50.57

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

8/1/2017 Econo Café, Azúcar y Leche $12.99 $287.01

8/1/2017 Always 99 Vasos de café $2.31 $284.70

8/1/2017 Laboratorio Irizarry Guasch Laboratorio $15.00 $269.70

8/4/2017 Supermercado La Placita Tolin Artículos Planta Física $12.11 $257.59

8/4/2017 Kmart Artículos Planta Física $28.97 $228.62

8/10/2017 La Casa de los Tornillos Abrazadera $22.41 $206.21

8/18/2017 Puma Azucar y café $6.37 $199.84

8/23/2017 USPS Carta Certificada y Acuse de Recibo $19.77 $180.07

8/23/2017 Always 99 Vasos de café $3.31 $176.76

8/24/2017 Puma Café $2.25 $174.51

8/25/2017 Kmart Azucar y café $21.79 $152.72

8/31/2017 USPS Carta Certificada y Acuse de Recibo $13.90 $138.82

$138.82

MONTH-END BALANCE: $138.82

TOTAL OF EXPENSES: $161.18

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Septiembre/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $138.82

REIMBURSEMENT PAID: $161.18

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

Plan de Contigencia Irma
9/8/2017 Walgreens $29.54 $270.46
Materiales para realizar Boletín Educativo
9/13/2017 Office & School Outlet (Nutrición) $16.85 $253.61

9/14/2017 Walgreens Café y alcohol $9.90 $243.71

9/17/2017 Little Caesars Plan de Contigencia Maria $20.06 $223.65

9/1717 Puma Café y leche $3.57 $220.08

9/17/2017 Puma Degreaser y espoja de brillo $5.46 $214.62

$214.62

$214.62

$214.62

$214.62

$214.62

$214.62

$214.62

MONTH-END BALANCE: $214.62

TOTAL OF EXPENSES: $85.38

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Octubre/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $214.62

REIMBURSEMENT PAID: $85.38

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

café, cremora, azucar y leche
10/2/2017 Mr. Special $26.63 $273.37
vasos para café, filtros y azucar
10/11/2017 Econo $7.48 $265.89

10/11/2017 Walgreens leche y café $3.78 $262.11

2 pqt de Café
10/13/2017 Puma (Gasolinera) $6.38 $255.73
1 pqte café y azúcar
10/31/2017 Puma (Gasolinera) $5.04 $250.69
9/23/2017 Desayuno para Staff(RN)
(Plan de Contingencia) Ricomini (Panadería) $11.76 $238.93
9/27/2017 1 pqt pequeño de Café
(Plan de Contingencia) Puma (Gasolinera) $2.25 $236.68

10/7/2017 Puma Carbonell Combustible $20.00 $216.68

10/7/2017 Puma Carbonell Combustible $12.00 $204.68

$204.68

$204.68

$204.68

$204.68

MONTH-END BALANCE: $204.68

TOTAL OF EXPENSES: $95.32

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Noviembre/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $204.68

REIMBURSEMENT PAID: $95.32

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

11/1/2017 Kmart Ziplock para dividir alimentos $11.34 $288.66

11/2/2017 Pueblo Bolsas para dividir alimentos a Empleados $27.60 $261.06

11/15/2017 Econo Café $4.23 $256.83

11/17/2017 Always 99 Artículos Salón Comedor $7.41 $249.42

11/20/2017 Puma Café $4.00 $245.42

11/20/2017 Ferretería Santana Materiales área técnica $15.53 $229.89

11/21/2017 Puma 3 Hielo $2.98 $226.91

11/21/2017 Walmart Artículos Salón Comedor $87.43 $139.48

11/22/2017 Pueblo Azúcar, leche, café y vasos $18.89 $120.59

11/27/2017 Puma 3 Café $4.34 $116.25

11/27/2017 Walmart Artículos Salón Comedor $27.84 $88.41

$88.41

$88.41

MONTH-END BALANCE: $88.41

TOTAL OF EXPENSES: $211.59

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Junio/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $102.54

REIMBURSEMENT PAID: $197.46

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

6/2/2017 Puma Café, leche y azúcar $6.38 $293.62

6/6/6/17 Puma Café $18.00 $275.62

6/16/2017 El Mesón Desayuno Reunión QAPI $13.05 $262.57

6/16/2017 Econo Azúcar, Agua y Vasos para Café $7.37 $255.20

6/23/2017 Metropolitan Lumber Area Tecnica (te pvc y cap) $2.16 $253.04

6/23/2017 USPS Carta Certifiada y Acuse de Recibo $7.29 $245.75

6/27/2017 Puma Café, Azúcar y Leche $5.29 $240.46

6/27/2017 Ferretería Santana Area Tecnica $13.36 $227.10

6/28/2017 USPS Carta Certifiada y Acuse de Recibo $13.18 $213.92

6/29/2017 Puma Café y Leche $5.82 $208.10

6/30/2017 Puma Café, leche y azúcar $12.50 $195.60

$195.60

$195.60

MONTH-END BALANCE: $195.60

TOTAL OF EXPENSES: $104.40

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Plan de Contingencia Septiembre, Octubre, Noviembre
Facility: San Germán
Amount Approved: $500.00

BALANCE

PRIOR BALANCE: $500.00

REIMBURSEMENT PAID: $0.00

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $500.00

Combustible
9/22/2017 Rafael H. Corales $160.00 $340.00
Artículios de Supermercado (alimentar Staff)
9/26/2017 Napo Velez $48.85 $291.15
desayuno para mantener staff = por escases alimentos y
9/26/2017 Panadería lugares de comida $14.15 $277.00
desayuno para mantener staff = por escases alimentos y
9/26/2017 Panadería lugares de comida $4.92 $272.08

9/27/2017 Claro Celulares $117.03 $155.05

Comida para Staff
9/27/2017 Marengos $18.75 $136.30
Combustible
9/27/2017 Garage Total $30.00 $106.30

9/29/2017 Golfer Gas Park Combustible $15.83 $90.47

10/1/2017 Garage Total Combustible $37.00 $53.47

9/26/2017 Napo Velez bolsa rehusable $0.11 $53.36

10/16/2017 Ultra Top Fuel Hormigueros Combustible $20.00 $33.36

10/1/2017 Golfer Gas Park Combustible $40.00 -$6.64

-$6.64

MONTH-END BALANCE: -$6.64

TOTAL OF EXPENSES: $506.64

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Diciembre/2017
Facility: San Germán
Amount Approved: $300.00

BALANCE

PRIOR BALANCE: $88.41

REIMBURSEMENT PAID: $211.59

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $300.00

12/1/2017 Puma Azucar $5.61 $294.39

12/4/2017 USPS Envio de Paquete $12.75 $281.64

12/5/2017 Puma Café $3.19 $278.45

12/7/2017 Puma Café y leche $9.09 $269.36

12/9/2017 Puma Filtros para Cafetera $1.17 $268.19

12/19/2017 Puma Café $2.25 $265.94

12/27/2017 Puma Café $2.25 $263.69

12/30/2017 Puma Café $2.25 $261.44

$261.44

$261.44

$261.44

$261.44

$261.44

MONTH-END BALANCE: $261.44

TOTAL OF EXPENSES: $38.56

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)

 Atlantis Health Care Group of Puerto Rico Inc.
Petty Cash Reconciliation Sheet
Month/Year: Diciembre/2017 Fiesta Empleados Navidad
Facility: San Germán
Amount Approved: $625.00

BALANCE

PRIOR BALANCE: $625.00

REIMBURSEMENT PAID: $0.00

DATE PROVIDER DESCRIPTION OF EXPENSE AMOUNT BEGINNING BALANCE: $625.00

12/23/2017 Pueblo Papel de Aluminio $1.39 $623.61

1/4/2018 Charry Mar Rest. Almuerzo Personal Administrativo $48.93 $574.68

12/23/2017 Pueblo Desayuno para el Personal $72.75 $501.93

12/23/2017 Walmart Gift Card $500.00 $1.93

$1.93

$1.93

$1.93

$1.93

$1.93

$1.93

$1.93

$1.93

$1.93

MONTH-END BALANCE: $1.93

TOTAL OF EXPENSES: $623.07

AMOUNT FOR REIMBURSEMENT:

Prepared By: Certified By:

Date:

Form: ACT 101-1 (Rev. 11/15/2016)