Section B - Accuracy of Reported Costs: CERTIFICATION BY OWNER,PARTNER OR OFFICER Provider Name : __________________________________ Vendor Payment Number: ______________ Reporting Period : From:(MO/DA/YR) _______________To:(MO/DA/YR) _______________ I declare and affirm the penalties of perjury that this cost report and supporting schedules have been examined by me and, to the best of my knowledge and belief, are a true and correct statement of total operating expenditures, balance sheet, earnings and expenses. Further, I declare that the report and supplemental information were prepared from the books and records of the provider, unless otherwise noted, in accordance with applicable regulations and instructions. I understand that any payment resulting from this report will be from state and federal funds and that any false statements or documents, or the concealment of a material fact, may be prosecuted under applicable federal and state laws. I also understand that this report and supporting schedules are subject to audit and verification by the Center for Health Information and Analysis or any other state or federal agency or their subcontractors. I will keep all records, books, and other information pertaining to this cost report for a period of five years. If there is an unresolved audit exception, I will keep these records until all issues are resolved. below the Name of the Owner, Partner, or Officer authorizing this certification: Last Name First Name Middle Name By signing below I hereby certify that I am the authorizing person noted above. Signature of Authorized Cost Report Submitter: Date of Authorization(MO/DA/YR):
Section B - Accuracy of Reported Costs: CERTIFICATION BY OWNER,PARTNER OR OFFICER Provider Name : __________________________________ Vendor Payment Number: ______________ Reporting Period : From:(MO/DA/YR) _______________To:(MO/DA/YR) _______________ I declare and affirm the penalties of perjury that this cost report and supporting schedules have been examined by me and, to the best of my knowledge and belief, are a true and correct statement of total operating expenditures, balance sheet, earnings and expenses. Further, I declare that the report and supplemental information were prepared from the books and records of the provider, unless otherwise noted, in accordance with applicable regulations and instructions. I understand that any payment resulting from this report will be from state and federal funds and that any false statements or documents, or the concealment of a material fact, may be prosecuted under applicable federal and state laws. I also understand that this report and supporting schedules are subject to audit and verification by the Center for Health Information and Analysis or any other state or federal agency or their subcontractors. I will keep all records, books, and other information pertaining to this cost report for a period of five years. If there is an unresolved audit exception, I will keep these records until all issues are resolved. below the Name of the Owner, Partner, or Officer authorizing this certification: Last Name First Name Middle Name By signing below I hereby certify that I am the authorizing person noted above. Signature of Authorized Cost Report Submitter: Date of Authorization(MO/DA/YR):
2014-HCF-2-NH.docx