Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 630 - MATERNAL AND CHILD HEALTH SERVICES CODE › Subpart D - ADMINISTRATIVE REQUIREMENTS › Appendix C - Instructions for Completing Reimbursement Certification Form

Current through Register Vol. 48, No. 28, July 12, 2024
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).
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,
				  2nd 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
AGENCY NAME: Sangamon County
Health Department
ADDRESS: 1234 West Fifth Street
FEIN NUMBER: 20-0000167
PROGRAM: WIC
CONTRACT #: 87G30027
BILLING PERIOD: 7/1/87 - 7/15/87
DATE SUBMITTED: 7/22/87
NAME/VENDOR
TITLE/PURPOSE
PERIOD/DATE INCURRED
VOUCHER/ CHECK #
Mary Jones
Nurse
7/1/87-7/15/87
Payroll
Sally Smith
Nutritionist
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