REQUEST FOR 2012-13 NHAP BILLING COVER SHEET FORM REGIONS 1-6 ONLY
QUARTER (check one)
☐1st Quarter (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, select a NHAP Primary Activity from the dropdown list and then (if applicable) select a NHAP Secondary Activity from the dropdown list. Enter the total NHAP amount requested for each line. Click Enter. The spreadsheet will automatically calculate the ESG, HSATF 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 with the completed NHAP Billing Form to Courtney Parker, NHAP, DHHS 4th Floor, PO Box 95026, Lincoln, NE 68509-5026 or
☐CHECK IF REQUEST INCLUDES AUDIT COST. AMOUNT: Enter audit amount
NHAP Billing Forms & Instructions: http://dhhs.ne.gov/children_family_services/Pages/fia_nhap_nhapindex.aspx
Print Name of Authorized Official: Enter name
Email Address: Enter email address Phone Number: Enter phone number
_______________________________________________________________________________________________________________
Signature of Authorized Official Date