Get ND SFN 1763 2020-2024

Vendor/ Provider Name REQUEST FOR REIMBURSEMENT- DIRECT SERVICE ND DEPARTMENT HUMAN SERVICES OF FISCAL ADMINISTRATION PAYEE CERTIFICATION Address Line 1 SFN 1763 Rev. 09-2005 Clear Fields Line 2 See reverse for instructions on completing this form. City CONTRACT INFORMATION State Column A Total Expenditures Previously Claimed This Billing Period Cumulative To Date Contract Award Including all Amendments Description of Service Total Matching In-Kind if Allowable Reported Zip Code Matching Salaries Fringe Benefit Employees I hereby certify that this request accurately reflects expenditures for services rendered in accordance with an agreement between the above and the North Dakota Department of Human Services that fund requirements have been complied with and that such compliance is documented for audit purposes. Is this the final reimbursement request Payee Signature Columns E F Date Only Payee Telephone Number Travel DHS Contract Number Consultation Services DEPARTMENT APPROVAL Equipment Program Director By Supplies Training Other List Separately Division Director Administration/Indirect Costs Contract Period Sub-Total From Billing Period To Less Advances/Program Income DHS FINANCE USE ONLY REF LINE Accounting Period Date Liaison Accountant Received To Date Total Amount Requested for Reimbursement This billing period Speed Chart Dept. ID Class Expended To Date Remaining Balance Program Income Fund Project Activity Resource Type Category TRANSACTION AMOUNT DISTRIBUTION White/Canary - Finance Canary - returned to vendor/provider with check Pink - retained by vendor/provider N*D. Department of Human Services/Fiscal Administration GENERAL INFORMATION BOXES City State Zip Enter a short description of the services provided by your organization under this contract. Enter the 8-digit Contract Number - assigned to the contract by DHS on the line provided please refer to your organization s finalized copy of the contract. Enter the beginning date and ending date of this contract - including all extension periods by amendment. Please note If the contract number has changed it is not an extension or amendment - it would then be a new contract - refer to your contract for this information. Enter the name for your organization as it should appear on the reimbursement check. Enter the full mailing address for your organization as it should be to mail the reimbursement check. Enter the City State and Zip Code for your organization as it should be to mail the reimbursement check. SPECIFIC INFORMATION BOXES Enter the total amounts claimed by Expenditure Classification as recorded on the most recently submitted SFN 1763 Column C. Enter the amount being claimed for reimbursement by Expenditure Classification on this SFN 1763. Enter the sum of Expenditures for each column A through C. Total the amounts recorded in Column A and B in Column C. Enter the Sum of the rows Sub-Total and Less Advances/Income for Columns A through C. to Further Project request for this contract Enter the Program Income Received Expended and the Remaining Balance when the vendor has been given specific approval from DHS to add Program Income to funds committed to further program objectives.