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RFO Attachment 2 3 1 2017 Redacted PDF

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Preview RFO Attachment 2 3 1 2017 Redacted

tachment 22 Office of Administration Commissioner's Office ‘RSIMBURSEMENT REQUEST FOR OTHER SERVICES Program: Alternatives to Abortion Contractor: __alance tor Lite — Subcontractor: __Lifline Pregnancy Care Center Kreme bequeath iubzmation aah Remn/servce io he purchased Lis the dap of purchase, Heme purehated costior the tem. andthe ustitcatos. aber mnae be ae ae pe purchased provided tobe rember iene Nome Dave Enrolled 03/22/16 Proposed Purchase Tosa Cost Tastfcstion, include other Date (include formal | souraes of funding that have esate from been attempted provider ofservices) | Car Repair 306.24 ‘ar isbroken down unable aya to drive to got doctor, case management of parenting class, No ‘other sources are available in our area ‘Ant be reimbursed] EES I efeletna ens and services ore not egbie fr reimbursement: totes travel epensen shipping Heege yetrnce interest ponate, termination payments aterhey ees ea awa ‘damages Plea subtract these charge from your total eimbursemen request ive oe Authorized person requesting purchase: ___Losi Amato. ‘lance for Life Program Manager: Purchase is Arproved “Denied __ A2A Siguavure 2 Lia, Reason for denying purchase f Tim's Auto Service & Sales, inc, waraavea 270 Hoy PP una MO. 95653 Phone: 873-665.8736 Fax: 679 965-0097 Eximele Dale 228/20"? 6m: vn ie Lae a Le RACE LNES 8 FIFI TE Gam HBNTEPUIGEREDR BRRELNESRHTFED 40) 2200 SerrmIns sisi : {xEREPLACE Sarre ast i500 fake Fd 1m 7a ta sarrenr + YEAR 190 tne ta sho Supple ‘ eR aT vm, ‘Signer Page al

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