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FY11 CFPI Methods (LARC), Sterilization and Training GRANT - YEAR 3 COST REIMBURSEMENT FORM NOTE: The following information is necessary in order to process your request. If the information is incomplete, your request will be returned. Please only submit SIGNED copies via FAX, MAIL or E-MAIL. TO: Colorado Department of Public Health and Environment CONTRACT/PO #: Prevention Services Division - A4 INVOICE #: ATTN: Julie Becker AGENCY NAME: 4300 Cherry Creek Drive South Address: Denver, CO 80246-1530 City, State Zip: Phone: 303-692-2431 FAX: 303-753-9249 FEIN #: E-Mail: firstname.lastname@example.org CONTACT NAME: CONTACT PH #: EXPENDITURE DATES: FROM _____________ TO________________ FINAL BILL? YES NO # of items purchased *Dates of or procedures Reimbursable Amount Service *Check # Description performed from CDPHE **LARC Methods (Invoices must be attached) Mirena # Cost--may include shipping Paraguard # Cost--may include shipping Implanon # Cost--may include shipping NuvaRing # Cost--may include shipping Subtotal LARC Methods $ - 10% Administrative and Handling $ - TOTAL LARC METHODS $ - Tubal Ligations # Cost + Referral ($100) Essure # Cost + Referral ($100) HSG # Cost (if billing separately) Vasectomy # Cost+ Referral ($50) TOTAL PROCEDURES $ - Training TOTAL TRAINING $ - * Necessary only if your agency cannot TOTAL Amount Requested for this period: $ - produce a detailed general ledger report or cost ledger that shows check or ** You MUST include vendor invoices for LARC Methods, but not for any other voucher number. services, unless CDPHE has instructed you otherwise. CONTRACTOR/VENDOR: I/We affirm the claimed expenses comply with the budget provisions of the contract and are reasonable and necessary, that all relevant progress or other reports have been timely filed, and all contract milestones and/or tasks related to the billing period have been achieved. Contractor/Vendor Signature Title Date CDPHE PROGRAM DIRECTOR/DELEGATED PROGRAM STAFF: I affirm that I or my staff have reviewed the contractor's invoice and suppporting documentation (as required), progress reports and other communication with the contractor, and believe to the best of my knowledge, that the contractor is in compliance with all contract provisions. CDPHE Program Director/Delegated Program Staff Signature Title Date CDPHE PROGRAM FISCAL OFFICER: I certify that the claimed expenses have been reviewed by me for compliance with requirements of the funding source and State of Colorado's Fiscal Rules, and are charged to the appropriate funding source. CDPHE Program Fiscal Officer Signature Title Date Instructions: Do not delete rows from the spreadsheet. Deleting rows will disable the formulas. You may however add rows to the spreadsheet. Submit invoices monthly. Submit signed copies via fax, mail or e-mail (scanned in). Payment will usually be processed within two weeks. Enter Agency name. Enter the name and phone number of the person to contact in the event of questions pertaining to the submitted reimbursement. Omitting this information can result in delay to your payment Indicate whether this is the Final Bill. Enter your Agency's billing period (dates) in the Expenditures from/to section. If you cannot attach a cost ledger or G/L detail, then you must enter your Agency's Check # for each reimbursable item Enter your Colorado Department of Public Health and Environment Contract # or Purchase Order #. The grantee must maintain records of revenues and expenditures by funding source, and produce verification of expenses upon request. A budget category may be overspent by no more than 10%. A Budget Modification Request is required for a variance of > 10%. The grantee may request a quarterly financial status report from the State.
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