Ill. Admin. Code tit. 77, § 630.APPENDIX B
| 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)