REQUEST FOR 2012 NHAP SOAR REIMBURSEMENT FORM
QUARTER (check one)
☐1st (Jul/Aug/Sep) due Oct 31
☐2nd Quarter (Oct/Nov/Dec) due Jan 31
☐3rd Quarter (Jan/Feb/Mar) due Apr 30
☐4th Quarter (Apr/May/Jun) due Jul 31
Agency Name: Enter agency name
Street Address: Enter agency address
City, State, Zip+4: Enter agency information
Agency NHAP Number (3 digits): Enter agency’s 3-digit NHAP code
INSTRUCTIONS: Double-click in the Table below and it will open as an Excel spreadsheet. For each line, enter allowable costs in the appropriate columns (e.g. Non-Training Related or Training-Related). Click Enter. The spreadsheet will automatically calculate Subtotal and Total amounts. When complete, click anywhere on this form to re-insert the completed Table.
Complete remaining grey fields. Print this document, obtain the necessary signature and email or mail it to: Courtney Parker, NHAP, DHHS 4th Floor, PO Box 95026, Lincoln, NE 68509-5026 or
Billing Forms & Instructions:http://dhhs.ne.gov/children_family_services/Pages/fia_nhap_nhap_funding.aspx
Print Name of Authorized Official: Enter name
Email Address: Enter email address Phone Number: Enter phone number
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Signature of Authorized Official Date