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N.C. Department of Health and Human Services <br />Division of Health Service Regulation <br />Offlce~of Emergency Medical Services <br />Page 1 of 1 <br />CONTRACT EXPENDITURE REPORT <br />(or Division-approved form) <br />mo yr expen i ure <br />Contract ID # <br />PO # <br />Contractor: <br />Total Expenditure: $ <br />Purpose: <br />Contractor Authorized Officer Signature and Date <br />Item# 37 <br />Attachment number 1 <br />Page 236 of 237 <br />As chief executive ofFcer (or title of person authorized to sign far reimbursement request} of the contracting <br />organization, I hereby certify that the cost or units billed on this form were incurred and delivered according to <br />the provisions of the contract. I further certify that any required matching expsndifures have been incurred, and <br />that to the best of my knowledge and belief we have complied with all laws regulations and contractual <br />provisions that are conditions of payment under this contract. <br />