Form 4116, Authorization for Expenditures

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Effective Date

8/2026

Instructions

Purpose

Use Form 4116 to organize data for entry into the Texas Health and Human Services Commission (HHSC) accounting system for HHSC authorized expenditures. Also use Form 4116 as part of an internal control process and to document required approvals.

Important

Make all purchases and the resulting accounting transactions per the Texas and United States Constitutions, applicable statutes and regulations, HHSC and the Texas Comptroller’s Office policies and rules.

The officer and employees are responsible for:

  • being knowledgeable about Texas law and rules concerning expenditures;
  • being knowledgeable about HHSC internal policies, standards and requirements concerning expenditures;
  • making sure the agency’s expenditure complies with those laws and rules;
  • determining the agency’s legal authority to make each payment before the document is submitted to the comptroller;
  • making sure that for each purchase document, the agency maintains necessary documentation to prove that each payment is legal, proper and fiscally responsible; and
  • making sure that each purchase document complies with the processing requirements of CAPPS Financials and USAS.

Note: Staff who make purchases outside applicable statutes, rules, policies and procedures may be held personally responsible for those purchases.

When to Prepare

HHSC employees should use Form 4116 for the following:

  • authorized emergency payments;
  • authorized unencumbered payments made per Health and Human Services (HHS) procurement policy;
  • vendor, contractor, or program area verification or certification of services;
  • employee reimbursements, such as manager-approved employee non-travel reimbursements made per HHS procurement policy;
  • notary application fees;
  • postage;
  • HHS printing services.
  • grants; and
  • other expenditures as authorized by the Approval and Signature Authority for HHS Agency Contracts Circular C-046.

Detailed Instructions

Section 1 – Payee Information

1. Vendor or Payee Name – Required. Enter the vendor or payee name.

2. Doing Business As (DBA) Name – Required if exists. Enter the DBA name, if applicable.

3. Texas Identification Number (TIN) – Required. Enter the vendor or payee’s 11-digit TIN number.

4. Mail Code – Required. Enter the three-digit mail code that correlates to the vendor or payee’s remit to address.

5. Address – Required. Enter the vendor or payee’s remit to address.

6. Phone No. – Optional. Enter the vendor or payee’s phone number and area code.

Section 2 – Invoice Information

7. Invoice No. – Required. Enter the invoice number using up to 30 alphanumeric characters. The invoice number is required for expenditure transactions. It must be unique for each payment.

8. Contract No. – Enter HHSC contract number, if applicable. This is needed to provide feedback payment information to SCOR.

9. Invoice Amount – Required. The invoice amount is the sum of all transactions entered for an invoice without regard to the accounting impact.

10. Discount Amount –  Optional. Enter the amount for any discount amounts the vendor or payee has provided.

11. Invoice Date – Optional. Enter the eight-digit invoice date (MMDDYYYY), if applicable.

12. Invoice Received Date – Required. Enter the eight-digit invoice received date (MMDDYYYY). This is the date that HHSC first received the invoice in strict accordance with any instructions on the purchase order (PO) or contract relating to the payment.

13. Service Begin Date – Required. Enter the eight-digit service date (MMDDYYYY) when services began. 

14. Service End or Delivery Date – Required. Enter the eight-digit service or delivery date (MMDDYYYY) when services or delivery are completed. This date identifies the date that goods or services are received or rendered.

15. Requested Payment Date – Optional. Enter the eight-digit requested date (MMDDYYYY) to establish a payment distribution date different than the payment due date, if applicable. Entry must comply with all policies and procedures.  Follow prompt payment guidelines for establishing this date. For early or advanced payment, you must provide justification in section 4.

  • SpeedChart – Enter the SpeedChart number. Important: Required entry for all payments.
  • RTI – Required for interagency payments (ITV) Only. Enter the six-character Recurring Transaction Index number for interagency transactions only. If multiple RTI numbers, break out the details on the additional entry lines.
  • Account or COBJ – Required. Enter the six-digit CAPPS expenditure account number (COBJ - comptroller object code).
  • Fund – Optional. Enter the four-digit fund or leave blank if it is to be inferred by CAPPS SpeedChart number, if applicable.
  • Dept ID – Optional. Enter the department ID or leave blank if it is to be inferred by CAPPS SpeedChart number, if applicable.
  • Program – Optional. Enter the program number or leave blank if it is to be inferred by CAPPS SpeedChart number, if applicable.
  • Class or PCA – Optional. Enter the five-digit Class or PCA or leave blank if it is to be inferred by CAPPS SpeedChart number, if applicable.
  • AY or BUD REF – Required. Enter the four-digit appropriation year (YYYY) that provides the funding for the expenditure.
  • Project Grant No. – Optional. Enter the valid project grant number or leave blank if it is to be inferred by CAPPS SpeedChart number, if applicable.
  • PO No. – Required if exists. Enter CAPPS HHSC purchase order number. 
  • PO Line – Required if exists. Enter CAPPS HHSC purchase order line number if a specific line of the purchase order is to be used with this payment line.
  • Quantity – Optional. Enter amount or number of an item/good.
  • Amount – Required. Enter the amount  and use up to 11 digits and two decimal places.

Section 3 – Description of Goods or Services

16. Description of Goods or Services – Required. Enter a description of the goods or services in enough detail.

Section 4 – Justification for Exception to Payment Scheduling

17. Justification – Required, if applicable. Enter a description of the HHSC policy or Comptroller exception for advanced, early payments.

Section 5 – Payee Verification or Certification and Program Approvals

18. Payee Verification or Certification Signature, Phone No. with Area Code and Payee Contact Name  – The payee must complete this section as a verification or certification that services were rendered per all terms and conditions.  This section only applies to program areas that require the payee verification per their contract terms. 

19. Program Signature Approval – Required if applicable. HHSC program staff that completed this form complete this section, if applicable.

20. Authorized Signature Approval – Completing this field is required. Only authorized HHSC staff given approval authority to enter or approve a payment may sign this form. Staff may not authorize payments if they are the requestor, payee or beneficiary of the services. 

Note: By approving this payment request, you confirm the above goods or services correspond with the contract or order under which they were purchased, the invoice for the goods or services is correct, and this payment complies with the General Appropriations Act.

Distribution

Send to Accounts Payable, Mail Code E-411 or forward electronic form to hhsc_ap@hhs.texas.gov.

Complete one form for each invoice received.