Free Electronic Expenditure Report Certification, F-80602, DMT-602 - Wisconsin

File Size: 15.0 kB
Pages: 1
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHFS
Word Count: 215 Words, 1,458 Characters
Page Size: Letter (8 1/2" x 11")

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DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80602 (07/08)



Completion of this form meets the requirements of s. 49.52 (2) (a), Wis. Stats. Failure to submit this form annually for Internet submissions may result in non-reimbursement of county/tribe claims under this section.

I certify that (Agency or Tribe Name)

(Agency Number)

(Agency Types)

has adequate internal controls in place to ensure the following:

1) Access to the agency/tribe records and equipment is limited to prevent the unauthorized submittal of expenditure information. 2) Expenditures, refunds, and adjustments reported via electronic mail in lieu of paper expenditure reports are just, true and correct in the amounts stated. 3) Monthly claims for reimbursement have not been previously reimbursed. 4) Costs reported represent actual and necessary costs of administering the provisions of the DHS contract(s). 5) That the final expenditure report for the contract period will be mailed and will contain total expenditures for the contract period and original signature of the authorized agency/tribe officer.

SIGNATURE County Treasurer or Financial Manager or Authorized Tribe Representative

Date Signed

Submit to:

Department of Health Services Division of Enterprise Services Bureau of Fiscal Services/CARS PO Box 7850 Madison WI 53707-7850

This Certification must be submitted annually.