Field 2: BILLING SERVICE NAME If applicable, enter the name of the billing service that the provider is enrolled. with. If you are not using a billing service, leave this field blank. Field 3: DATE Enter the date the Certification Statement is submitted to the fiscal agent.
Gregory Jerome Coleman (born September 9, 1954 in Jacksonville, Florida) is a retired American football punter who had a 12-year career in the National Football League playing for the Cleveland Browns, the Minnesota Vikings, and the Washington Redskins. He attended Florida A&M University.
Justin Paul Tucker is an American football placekicker for the Baltimore Ravens of the National Football League. He played college football for the University of Texas. He was signed by the Ravens as an undrafted free agent in 2012. As of 2017, he has the highest field goal accuracy of any kicker in NFL history.