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BK 00025 PG <br />N.C. Department of Health and Human Services <br />X63 <br />FOOD & LODGING LOCAL HEALTH DEPARTMENT REQUEST FOR PAYMENT <br />SFY 13 <br />Division of Public Health <br />04/01/2013 05/31/2013 <br />Effective Date Termination Date <br />Contractor. Lee County Health Department <br />Project Director. <br />1600105313 <br />NCAS Number <br />Activity Number 874 <br />Activity: Food & Lodginj Distribution <br />Distribution — indicate with a check mark all that apply <br />Rl 15A NCAS 18A.2901(1) ($750 Baseline distribution) <br />la 15A WAS 19A.2901(2)(a) (Distribution based on inspection percentage) <br />O 15A NCAS 18A.2901(2)(b) (Distribution based on 100% inspection rate) <br />AMOUNT REQUESTED 1 $5,229 <br />Note #1: LHD shall report Local Food and Lodging expenditures in the appropriate category (e. 101 <br />102, or 103) in the ZZZZ line item in the Aid to County Database. <br />Note #2: LHD shalt report Local Food and Lodging Temporary Food Establishment (TFE) fees collected <br />in category 107 — Local Temporary Food Establishment (TFE — State) in the ZZZZ line item in <br />the Aid to County Database. <br />THIS SECTION FOR DPH USE ONLY <br />Company Account Center <br />2B01 536560874 1153 -4752 -0453 <br />As chief executive officer of the recipient organization, I hereby certify that this request for payment is an accurate reflection of funds <br />to be disbursed in accordance with 15A NCAC 18A.2901 "Disbursement of Funds ". I further certify that to the best of my knowledge <br />and belief we have complied with all laws, regulations and contractual provisions that are conditions of payment under this agreement. <br />Local Authorized Weial Signature Branch Head <br />Finance Officer Signature Date Accountant Initials <br />Environmental Health Section Signature Date <br />DPH Budget Officer Signature Date <br />DPH EH 2948 (B) <br />