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.
Taylor Jonathan T. J.. Yates (born May 28, 1987) is an American football quarterback for the Buffalo Bills of the National Football League (NFL). He played college football at North Carolina and was drafted by the Houston Texans in the fifth round of the 2011 NFL Draft.