Re Re RFO Attachment 6 26 2017 Redacted PDF
Preview Re Re RFO Attachment 6 26 2017 Redacted
Atvoment 12 Office of Administration Commissioner's Office REIMEURSEMRNT REQUEST FOR OTILER SERVICES rogram: Alternatives to Abortion Contractor: Alans far ife Subcontractor: Presaney Cave Cente Pleace uuter below the innymation for each tem service to be purchases, List the date of purchase, ‘te to be purchased, cosrfor the item, and Uae justicaton, Items must be approved beta’ purchased Gent Nam: ate Burotled, a Proposed Parchase | Tera Total Cost Justification, inclade other ate (Gnoinde format | sources of landing that have i ‘ection rom. been attempted provider af services) . | a s eaiay Car Distrance monzhly | $209.80 HUDE Ice 10-15-16, She ls | premium for July 2017 following throngh with | zzcntnente ont ase | - ie recent eyed and elvered ter inby ia Moy by c soton 2 hay here able te wore. She scorn Uhinsured an tod Tea arte look or wort ws wel = ger t casas and ncresoer appoints, Theve are no ober Jes tata] soars mea ast een) in i rpense Tntobe sla Tear HG 2 BO The following items and services are nat eligible for rotmbursement: axes, ravel enpcates shipping ‘charges insurance, terest, pennies, termlaation payments, attorney fees, and liguidated damages ‘Mease subiract these charges from your total relmbureament request prior to submassion. ‘Authorized person requesting purchase: _fanet Duss Alllance for fe Progeas “ps Daraclvapworet Zones. aries eb Fai pa /@HL7 Reason for denying pusease:—
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