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.
Anthony Darelle Booger McFarland (born December 18, 1977) is a former American football player. He was drafted by the Tampa Bay Buccaneers 15th overall in the 1999 NFL Draft. He played college football at Louisiana State University. McFarland also played for the Indianapolis Colts.