ILLINOIS DEPARTMENT OF HUMAN SERVICES

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