Fillable Christian County CARES Act Reimbursement Request Form (Christian County Government)

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Christian County CARES Act Reimbursement Request Form (Christian County Government)

On average this form takes 12 minutes to complete

The Christian County CARES Act Reimbursement Request Form (Christian County Government) form is 2 pages long and contains:

  • 1 signature
  • 4 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Christian County Government

BROWSE CHRISTIAN COUNTY GOVERNMENT (MO) FORMS

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Christian County CARES Act Reimbursement Request Form
Christian County CARES Act Committee
1106 W. Jackson St. Phone: (417) 581-7242
Ozark, MO 65721 Email: caresact @christiancountymo.gov
(separate information must be provided for each invoice/vendor)
Copies of paid invoices or receipts must accompany all requests
Contact Information and Address for Reimbursement to be Sent
Name of Entity Making Request:
Name:
Title:
Address:
Telephone:
Email:
Itemized Listing of Expenditures
Please provide the following information for any items for which you are requesting reimbursement:
Brief Description/Note
Inv./Req No.
Date
Total
Application No.: _________________ Date Received: _________________
Please provide a brief explanation of how this expenditure is eligible for reimbursement under CARES Act
guidelines
Have you requested or received funding from any other source or program with regard to the items
listed in this reimbursement request? No Yes
Are you eligible to receive funding from another source for any of the items listed in this request?
No Yes
In signing this request for funding, I certify that the information provided is true and accurate to best of
my knowledge and that the funding requested is reimbursement for expenditures made, related to the
COVID-19 emergency and identified as eligible under the CARES Act.
Signature of authorized official:
_________________________________________________
Date:
________________________
Printed name:
Title:
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Christian County CARES Act Reimbursement Request Form (Christian County Government)

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Completed 19 January 2021

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