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