Full Text
Return to: Clay County Social Service Center 715 11th Street N, Suite 102 Moorhead, MN 56560 Payment Payment type: Payment status: Service arrangement: Service arrangement Service start date: Service end date: Client name: SSIS person Workgroup: Vendor Name: County vendor SSIS bus. org. # Address: Address: Payee vendor: County payee vendor#: SSIS bus. org # License IV-E sub code: Program: Service: County sub-service: Location: Special cost code: DOC points: Basic per diem: Rate: Unit type: # of units: Amount: SEAGR unit type: SEAGR units: Chart of accounts: Accrual code: IVE reimbursable: Yes No 1099: Yes No Vendor Signature: Date: Approval Signature: Date: I/We declare under penalties of perjury that I/We are making the within claim; that I/We have examined said claim and that the same is just and true, that the money/service therein charged was actually paid/perfomed for the purpose therein stated; that the services charged are official and are such as are allowed by law; and no part of said claim has been paid. Vendor Address: Vendor Address: Vendor Name: Service Description