[LE-20] Lead Testing & Mitigation Reimbursement Form

[LE-20] Lead Testing & Mitigation Reimbursement Form

For License Exempt Family Child Care Providers Participating in ERDC Subsidy
Requirements for payments:
1. Completed lead testing from an ORELAP Approved Lab and submitted the results to CCLD.
2. If test had failed, purchased and installed needed filters or completed other mitigation steps.
3. Receipt/s for any corrective/mitigation costs.
4. 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
ERDC Provider #
Do you provide childcare to infants or toddlers (ages 0-3)?
Phone #
Format: (000) 000-0000.
Email
example@example.com
Date of Testing
MM/DD/YY
Number of Test Results
Name of ORELAP Lab
Amount
- Date - Purchase and installation of an approved National Sanitation Foundation (NSF) certified lead filter
- Amount
- Receipt
  
  Cancelof
- Date - New faucet and installation
- Amount
- Receipt
  
  Cancelof
- Date - Lead test shipping cost (on lab receipt)
- Amount
- Receipt - Shipping fees are only reimbursable if included on the lab receipt.
  
  Cancelof
- Payment Information: (Must match WOU Substitute W-9).
- Name of business/Individual requesting payment
- Street Address
- City, State, Zip
- Signature
- Date
  
  MonthDayYear
  Date

Demographics Questionnaire