Pre Auths Attachment 2 5 22 2017 Redacted

3.1 MB·English

Office of Administration

Commissioner's Office

“Request for reauthorization for Other Services”

Program: Alternatives to Abortion

Contractor: Nurses for Newborns

Subcontractor: N/A.

Please enter below the information for each item/ervice to be purchased. List the date of purchase,
item to be purchased, cost forthe item, and the justification, Items must be approved before
purchased provided to be reimbursed.

Proposed
Purchase
Date

item

Total Cost

(include formal

estimate from
provider of

Justification, include other sources
offunding that have been
attempted

sepaces)
Car repair for transmission. | ¥
05/08/17 | including parts and Labor

(24.4%

Oniy car availabe for
transportation. Only one parent
working at the moment and would
appreciate any help and support
with payment,

211 united way
Mercy neighborhood ministries
United way

Personal owner of car repair shop.

| AMOUNT TO BE REIMBURSED

lease return to Alternatives to Abortion Program Manager, State of Missouri - office of
Administration, Commissioner's Office, State Capitol Building, Room, 125, Jefferson City, MO
‘65101. May be faxed to 573/751-1212 or emailed to [email protected]

by the Contractor onty!
Thankyou.

‘Authorized person requesting purchase:

Approved for purchase:
Purchase denied

Reason for denying purchase:

Dat

Date