The governmental entity shall ensure the funds provided to the department in the IGT meet the requirements of 42 CFR 433, Subpart B, and R414-513. Funds shall not be derived from an impermissible source, including recycled Medicaid payments, Federal money precluded from use as the non-Federal share, impermissible taxes, and non-bona fide provider-related donations.

Below, state, in detail, the source and legal basis for the IGT monies.

Source of Seed

Detailed Description and Legal Basis

Amount

Below, state the payment to which this form applies.

Payment Type	Fiscal Year	Fiscal Quarter	OR	Invoice Number
If “Other” selected for Payment Type, please specify.

I certify under penalty of law, including but not limited to U.C.A. § 76-10-1801, § 76-6-412 and § 76-8-504, that the foregoing is true and correct and that by my signature I acknowledge and affirm that I executed this instrument in my own capacity or in an authorized capacity for the governmental entity.

___________________________________

(Governmental Entity Name)

___________________________________ ___________________________________

(Signatory Printed Name) (Signatory Signature)

___________________________________ ___________________________________

(Signatory Title) (Signature Date)

Jurat

State of Utah, County of __________________ (County)

Signed and sworn to before me on _________________________ (Date) by

______________________________________________________(Name and title of document signer); I further acknowledge that the signer was personally known to me or did prove on the basis of satisfactory evidence, has made in my presence a voluntary signature and taken an oath or affirmation vouching to the truthfulness of this document.

________________________ ___________________ (Notary Seal)

(Signature of Notary Public) (Commission Expires)