Request for Reimbursement - Direct Services (SFN 1763) 650-25-85-05

(Revised 1/1/06 ML#2995)

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The Request for Reimbursement – Direct Services (SFN 1763) is due at Aging Services Division no later than thirty days after the end of the monthly service period. The State will make payment within thirty days after receipt of the request for reimbursement and required reporting. No payment will be made until the reimbursement and reporting have been approved by the State. The State will not make any advanced payments before performance by the contractor. Submission of incomplete or inaccurate reports may result in delayed payment. Instructions for completion are outlined on the back of the form.