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Benefit Funds Statement

Statement Period: Oct 1, 2026 – Oct 31, 2026

Generated: November 3, 2026 · 3:35 PM

Maya Thompson
Health1st ID: H1-1048
Medical Record Number (MRN): MRN-48291
Master Client Index (MCI): ENC-MC•••
Case & Account Status
Account Status: ACTIVE
PA ABLE Account: Established
Effective Coverage Start: Jan 15, 2025
Government Benefits
$1,120.00
Additional Income
$1,370.00
Total Expenses
$42.00
Net Cash Flow
$2,448.00

Itemized Statement Activity

Date Type Description & Payee / Source Status Amount (USD)
Oct 20, 2026 Income (gift) Family Gift - Family monetary gift RECORDED +$250.00
Oct 17, 2026 Expense Metro Transit Access - Medical specialist appointment transport voucher RECORDED −$42.00
Oct 1, 2026 Benefit Monthly government benefit CONFIRMED +$1,120.00
Oct 1, 2026 Income (government_benefit) October Government Benefit - October SSI/SSDI Deposit RECORDED +$1,120.00
Fiduciary & Compliance Certification

This statement reflects all financial benefits received and disbursements made on behalf of the individual by Health1st Home Health Services in accordance with SSA Representative Payee and state benefit fund management guidelines.

Authorized Health1st Signoff
Date: 11/03/2026