§630.APPENDIX B. Illinois Department of Public Health Reimbursement Certification Form  


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  • ILLINOIS DEPARTMENT OF PUBLIC HEALTH

    REIMBURSEMENT CERTIFICATION FORM

     

    page

    of

    AGENCY NAME:

    PROGRAM:

    ADDRESS:

    CONTRACT #:

    FEIN NUMBER:

    BILLING PERIOD:

    DATE SUMITTED:

     

     

    NAME/ VENDOR

    TITLE/ PUR- POSE

    PERIOD /DATE INCURRED

    VOUCHER /CHECK #

    GROSS AMOUNT

    AMOUNT CLAIMED FROM IDPH

    Agency Match/ WIC Admin

    Nutrition Education

     

    CERTIFICATION:

    TOTAL

    I hereby certify that the goods and/or services claimed above are necessary expenditures for the program and are a part of the approved budget, that appropriate purchasing procedures have been followed and that payment has not previously been requested or received.

     

     

     

    Authorized Agency Official

     

    (Source:  Added at 14 Ill. Reg. 11219, effective July 1, 1990)