Ill. Admin. Code tit. 77, pt. 630, subpt. D, app B
Current through Register Vol. 49, No. 2, January 10, 2025
ILLINOIS DEPARTMENT OF PUBLIC HEALTH REIMBURSEMENT CERTIFICATION FORM | ||||||||||
page | of | |||||||||
AGENCY NAME: | PROGRAM: | |||||||||
ADDRESS: | CONTRACT #: | |||||||||
BILLING PERIOD: | ||||||||||
FEIN NUMBER: | 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 | ||||||||||
Ill. Admin. Code tit. 77, pt. 630, subpt. D, app B