TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER i: MATERNAL AND CHILD HEALTH
PART 630 MATERNAL AND CHILD HEALTH SERVICES CODE
SECTION 630.APPENDIX B ILLINOIS DEPARTMENT OF PUBLIC HEALTH REIMBURSEMENT CERTIFICATION FORM



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

 

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)