DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80601 (07/08)
STATE OF WISCONSIN
CERTIFICATE OF CLAIM
Completion of this form meets the requirements of s. 49.52 (2) (a), Wis. Stats. Failure to submit this form may result in non-reimbursement of county claims under this section. Submit To: DIVISION OF ENTERPRISE SERVICES BUREAU OF FISCAL SERVICES CARS Unit 1 West Wilson Street, Room 736 PO Box 7850 Madison WI 53707-7850 Agency Number Agency Type
Date Form Completed (mm/dd/yy)
Report Period (mm/yy)
County / Agency Name
I / We hereby certify the expenses, refunds and adjustments reported through electronic reporting media in lieu of the F-80600 are just, true, and correct in the amounts stated. Reimbursement is claimed pursuant to Section 49.52, of Wisconsin Statutes, and claimed costs have not been previously reimbursed. Further, these costs represent actual and necessary costs to administer the provisions of the State/County contract.
SUMMARY OF EXPENDITURE REPORT
HUMAN SERVICES PROGRAMS
TOTAL REIMBURSABLE EXPENSES
$
TOTAL NON REIMBURSABLE EXPENSES
$
TOTAL REPORTED EXPENSES
$
SIGNATURE - Treasurer or Financial Manager
Date Signed
SIGNATURE - Administrator
Date Signed