Spreadsheet: 02b7322e-8fbe-4d28-b763-d8285fd461eb
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10
 | MEDICAID SCHOOL COST REPORT |  |  |  |  |  |  |  |  | Complete Shaded Areas Only
 | Certification Statement
 | Provider Name and Address: |  |  |  |  |  | 123 School
 |  | Provider (District) Name | 123 School
 |  | Address line 1 | 123 Lane |  |  |  | 0123456
 |  | Address line 2 | optional
 |  | City, OH, zip code | Anytown, OH 99999 |  |  |  | 2009-10-01 00:00:00 |  | to | 2010-09-30 00:00:00
 |  | Reporting Period:
 |  | From: (DD/MM/YYYY) | 2009-10-01 00:00:00
 |  | To: (DD/MM/YYYY) | 2010-09-30 00:00:00
 | a.  Total Computable Expenditure by Type: |  |  |  |  |  | IRN   (Internal Retrieval Number): |  | 0123456
 |  |  |  | Total Computable
 |  |  |  |  |  |  | Medicaid Provider Number: |  | 123456789012
 |  | Medical Services |  | 0
 |  | TCM |  | 0 |  |  | National Provider Identifier (NPI): |  | 123456789
 |  | Administration |  | 2000.435208508256
 |  |  |  |  |  |  | [NAME]:
 |  | Transportation |  | 0
 |  |  |  |  |  |  | This statement is of expenditures that the undersigned certifies are allocable and allowable to the state
 |  |  |  |  |  |  | Medicaid program under Title XIX of the Social Security Act (the Act), in accordance with all procedures,
 |  | Total |  | 2000.435208508256 |  |  | instructions and guidance issued by the single state agency and in effect during the Year Ended
 |  |  |  |  |  |  |  | 00:00:00
 |  | INTENTIONAL MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED HEREIN
 |  | MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW.
 |  |  |  | CERTIFICATION BY OFFICER OF THE PROVIDER
 |  | I HEREBY CERTIFY that:
 |  | 1. I have examined this statement, the accompanying Supporting Schedules, the allocation of expenses and
 |  | services, and the attached Worksheets for the period from |  |  |  | 2009-10-01 00:00:00 | to | 2010-09-30 00:00:00
 |  | and that to the best of my knowledge and belief they are true and correct statements prepared from the books
 |  | and records of the Provider in accordance with applicable instructions.
 |  | 2. The expenditures included in this statement are based on the actual cost of recorded expenditures.
 |  | 3. All cost included herein comply with certified Public Expenditure (CPE) requirements and all local, state and federal requirements
 |  | (including that the funds were not Federal funds in origin, or are Federal funds authorized by
 |  | Federal law to be used to match other Federal funds, and that the claimed expenditures were not
 |  | used to meet matching requirements under other Federally funded programs).
 |  | 4.  Federal  funds are being claimed on  this report in accordance with the Cost Report instructions provided
 |  | by the ODE effective for the above reporting period.
 |  | 5.  I am the officer authorized by the referenced provider to submit this form and I have made a good faith
 |  | effort to assure that all information reported is true and accurate.
 |  | 6.  I understand that this information will be used as a basis for claims for federal funds, and possibly state funds, and that
 |  | falsification and concealment of a material fact may be prosecuted under federal or state civil or criminal law.
 | SIGNATURE (Officer of the Provider) |  |  |  |  |  | DATE (DD/MM/YYYY)
 | TITLE |  |  |  |  |  | PHONE NUMBER (XXX)XXX-XXXX
 |  |  |  |  |  |  | E-MAIL ADDRESS
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