August 1987

IDPH – OFFICE OF HEALTH SERVICES

Instructions for Completing the

Reimbursement Certification Form

Agency Name:

Fill in your agency's name, address and FEIN (Federal Employer's Identification Number or in the case of Local Health Departments, the Comptroller assigned County Identification Number) as it appears in the contract/grant agreement.

Program:

Fill in the name of the Department program for which you are requesting reimbursement.

Contract   #:

Fill in the contract number (located in the upper right hand corner of the executed contract/grant agreement).

Billing Period:

Fill in the period covered by the request. The period shown should include the earliest date goods/services were ordered through the latest date services were provided. This period will be used by Department staff to determine proper state, federal and/or project fiscal year. You must submit separate Reimbursement Certification Forms for different state, federal and/or project fiscal years. If you have questions, please consult with Department program or fiscal staff.

Date Submitted:

Fill in date Reimbursement Certification Form is completed or sent to IDPH.

Name/Vendor:

Enter the name of the employee, business or other payee to whom payment was made.

Title/Purpose:

For payroll, enter the title of the employee; for other items, briefly describe the goods or services purchased. (Please provide enough information so that program staff can determine appropriateness to program).

Period/Date:

Incurred:

For payroll, enter the period covered; for other items, enter the date the goods or services were received. In the case of supplies, equipment and other specific deliverables, it is a good idea to also note the date the order was made. This will assist program/fiscal staff to determine the proper state and/or federal fiscal year to be charged. This is required for all supplies and equipment received in lapse periods (after the end of the state or federal fiscal year).

Page  –2–

Voucher/Check

Number:

Enter the voucher or check number for the payment. This establishes the audit trail and is necessary to verify that payment has been made.

Gross Amount:

Enter the total amount of the check identified previously or for payrolls the gross pay for the employee.

Amount Claimed

from IDPH:

Enter the amount applicable to the program for which this Reimbursement Certification Form applies and for which you are requesting reimbursement.

Agency Match/

WIC Admin.:

For those programs which require the agency to provide matching support of Department expenditures, enter the amount of agency supplied match in this column. In most cases this will be a part of the difference between the Gross Amount column and the Amount Claimed from IDPH.

For the WIC program, each agency must identify the allocation of expenditures to either WIC Administration or Nutrition Education.  Since there is no matching requirement for WIC, the last two columns are to be used to show this allocation.

To further assist Department Program/fiscal staff, please list reimbursements by line item and show a sub-total for each line item.

In many cases, multiple pages will be necessary. In order to save some paper/copying charges, both sides of the Reimbursement Certification Form may be used. Please show the TOTAL on the final page only.

After review and approval, the authorized agency official shall sign the certification (only the final page which shows the TOTAL needs to be signed).

Forward the original and three copies of the Reimbursement Certification Form to:

Illinois Department of Human Services

Office of Health Services, Fiscal Operations Unit

535 West Jefferson, 2^nd Floor

Springfield, IL  62761

The Office of the State Comptroller no longer requires vendors to sign or otherwise certify to expenditures on the State of Illinois Invoice-Voucher, Form C-13; therefore, the Reimbursement Certification Form is all that is required to be submitted. The Department fiscal staff will complete the C-13 using information from your Reimbursement Certification Form.

SD/dm

8/12/87

ILLINOIS DEPARTMENT OF HUMAN SERVICES

REIMBURSEMENT CERTIFICATION FORM

Page 1 of 1

AGENCY NAME: Sangamon County

Health Department

PROGRAM:   WIC

ADDRESS: 1234 West Fifth Street

CONTRACT #:   87G30027

BILLING PERIOD:    7/1/87 – 7/15/87

DATE SUBMITTED: 7/22/87

FEIN NUMBER:  20-0000167

NAME/VENDOR

TITLE/PURPOSE

PERIOD/DATE

INCURRED

VOUCHER/

CHECK #

Mary Jones

Nurse

7/1/87-

Payroll

Sally Smith

Nutritionist

7/15/87

Voucher

Tim Johnson

Nutritionist

#2378

Nancy Adams

Clerk

Betty Clark

Clerk

Wanda Campbell

WIC Administrator

Subtotal, Personal Services

Sangamon County

Treasurer

Social Security,

Pension Medical

Insurance

7/1/87-

7/15/87

278976

Davis Supply Co.

Office Supplies

7/6/87

278834

Capitol Paper Co.

Paper Stock

7/10/87

278894

Subtotal, Supplies

Tim Johnson

Travel

7/1/87-

7/15/87

278975

GROSS

AMOUNT

AMOUNT CLAIMED

FROM IDPH

Agency Match/

WIC Admin

Nutrition

Education

1,145.50

572.75

477.25

95.50

1,200.00

1,200.00

300.00

900.00

1,200.00

900.00

300.00

600.00

500.00

500.00

500.00

550.00

412.50

412.50

1,400.00

1,400.00

1,150.00

250.00

4,985.25

3,139.75

1,845.50

15,728.56

1,096.75

690.75

406.00

327.57

86.40

86.40

250.00

250.00

200.00

50.00

336.40

286.40

50.00

377.82

162.37

162.37

TOTAL

6,580.77

4,116.90

2,463.87

CERTIFICATION

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