Re RFO Attachment 4 10 2017 Redacted

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Aashaeat 12

Office of Administration
Commissioner's Office

REIMRURSEMENT REQUEST FOR OTHEK SERVICES

Program: Alternatives te Abortion
CCoutructor Alliance for Lite

Swkcontractor: Pueguaney Care Center

Please enter below the information for wach i
Item to be purchased, cost for the:tem, and the justification, Wes must he appro

| Proposed Purchase Item Total Cost Justification, include other
| assist with this expense.

mjservice tobe purchased. List te date of prctase
‘before

Labor 358.00

‘The following tems and services are not eligible for reimbursement: taxes, ravel expenses, shipping
iaryes, insurance, interest, penalties, termination payments, attorney fees, and liquidated domoges.
‘Please subtract tnese charges from your total reimbursement request prior ta submission.

Authorized persan requesting prrhsse-_fanet Doss _

Alliance tor Lite Program Niarager: Carnie Hoelscher

Parehase is Approved \./ Denied A2A Signature © \. Date.

Reason for denying purchase: —_
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