Laserfiche WebLink
<br />INSTRUCTIONS FOR COMPLETING REQUEST FOR REIMBURSEMENT <br />(Form GC-10 <br /> <br />I:em 1 - Type of payment: Reimbursement <br />2 - Basis of Request: Cash <br />3 - Sponsoring Agency: TDH-Bureau of Dental Health Services <br />4 - Contract Document Number: (Obtain from contract) <br />5 - N/A <br />6 - State of Texas Vendor I.D. Number: (Obtain from Contract) <br />7 - N/A <br />8 - Period Covered by Report: (Date contract to completion <br />date of installation.) <br />9 - Grantee's name, address <br />1.0 - N/A <br />11. - Computation of Amount of Reimbursement Requested: <br /> <br />a. Enter ending date of period from Item 8. <br />Column (a) - Enter total program expenditures (which <br />are allowable within amount of Contract) <br />Column (b) - N/A . <br />Column (c) - N/A <br />Total - Bring from Column (a) <br />b, N/A <br />c. Same as Item l1.a <br />d. N/A <br />e. Same as Item l1.a <br />f. N/A <br />g. Same as Item l1.a <br />h. Enter total of previous payments. <br />i. Enter payment now requested. <br /> <br />1.2 - N/A <br />13 - Name, Signature, Phone Number <br /> <br />Return completed for.ms to: <br /> <br />BUREAU OF DENTAL HEALTH SERVICES <br />TEXAS DEPARTMENT OF HEALTH <br />1100 WEST 49TH STREET <br />AUSTIN, TX 78756-3199 <br />