Pike County EMS Proof of Payment

Pike County EMS Proof of Payment
Municipality Name*
Contact Person*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Time Period for Report*

January 1 - March 31, 2025April 1 - June 30, 2025July 1 - September 30, 2025October 1 - December 31, 2025
Please provide confirmation that the County matching funds have been sent to the EMS provider. County funds must be forwarded to the EMS provider within 10 days of receipt.

Cancelof
Enter the total amount sent to provider.*
Signature*

Clear
Name of Person Submitting Report*

First NameLast Name
Today's Date*

MonthDayYear
Date
Should be Empty: