Get Wi Dhs F-47255 2019

Filling out the WI DHS F-47255 form is essential for municipal signature and population verification for the Emergency Medical Services Funding Assistance Program. This guide provides a clear, step-by-step approach to help users complete the form accurately and efficiently online.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the WI DHS F-47255 form and open it in your preferred online editor.
2. Begin by entering the ambulance service provider information. Fill in the name of the licensed provider, provider number, complete mailing address, telephone number, federal employer ID number, and email address.
3. Proceed to the certification section for municipality or contracting agency. List all municipalities included in your primary service area. Ensure each municipality certifies the actual population served and the percentage representation.
4. For each municipality, fill in the municipal code, the total population served, and the percentage of the total population that this represents. If multiple municipalities are involved, you can copy the certification section as needed.
5. Complete the certification statement by having the municipal clerk sign and date the form to validate the information provided.
6. Once all sections are completed, review the form for accuracy. Save your changes, download the completed form, and if needed, print or share it as required.

Begin completing the WI DHS F-47255 online today to ensure your application is submitted accurately.