By signing this form, I attest that services have been delivered and received consistent with the participant’s approved care plan and that this payment request is in accordance with the AW Program regulations. I understand that payment of this claim will be from Federal and State funds, and that false claims, statements or documents or concealment of a material fact may be prosecuted under applicable Federal or State laws. Any misuse of funds may result in being fined or penalized, including but not limited to repayment of a claim.