(Address)___________________________________________________________

(Municipality/Organization)_______________________ (Telephone No.)______________

Approved for:
CMFO - 2 Accounting & 2 Financial and Debt Management
CTC - 1 Enforcement, 1 Legislation & 2 Reporting Billing & Collection
CPA & RMA - 4 Accounting CPE's

CLAIMANT'S CERTIFICATION & DECLARATION

I do solemnly declare and certify under the penalty of law that the within bill is correct in all its particulars, the articles have been furnished or services rendered as stated herein, that no bonus has been given or received by any person or persons within the knowledge of this claimant in connection with the above claim, and that the amount charged is a reasonable one.

Just send your check with the application form! You do not need to send us your voucher for a separate signature since the pre-signed certification at the left can be attached to your voucher in lieu of sending another one for signature. This form has been determined by the Division of Local Government Services to meet the requirements of the statutes for this type of expenditure.