REIMBURSEMENT FORM by ME18e9X

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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: julie.becker@state.co.us                                                                        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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