Chief or Chief Designee Signature ________________________________________________________

Print Name: ______________________________________________________________________________

THE PROVIDER MUST LEAVE THE DEPARTMENT COPIES OF THE COMPLETED REIMBURSEMENT FORM AND INVOICE(S) FOR THEIR RECORDS PRIOR TO SUBMISSION TO MBFTE

PROVIDERS WILL NOT BE PAID DIRECTLY FROM THE MBFTE FOR ANY PART OF AN INVOICE THAT EXCEEDS THE FIRE DEPARTMENT’S AWARD AMOUNT AND SHOULD SEEK PAYMENT DIRECTLY FROM THE FIRE DEPARTMENT.