[L-13] Lead Testing Reimbursement Form

[L-13] Lead Testing Reimbursement Form

For Licensed Child Care Providers
Requirements for payments:
1. Completed lead testing from an ORELAP Approved Lab and submitted the results to CCLD.
2. WOU Substitute W-9 with information verifiable with IRS.
Note: Rush processing fees are not reimbursable, and shipping fees are only reimbursable if included on the lab receipt.

Questions: 503-838-8008, tripayments@wou.edu
Program/Provider Name
Program License #
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you provide childcare to infants or toddlers (ages 0-3)?
Date of Testing
Number of Test Results
Name of ORELAP Lab
Amount
Include the following with this form: (Note: Forms with missing information will be held for payment until it is received.)
1. Lab receipt/s showing shipping fees, if applicable
2. WOU Substitute W-9
Lab receipt/s showing shipping fees, if applicable

Cancelof
Payment Information:

(Must match WOU Substitute W-9).
Name of business/Individual requesting payment
Street Address
City, State, Zip
Signature
Date

MonthDayYear
Date

Payment Information: