Pike County EMS Proof of Payment
Municipality Name
*
Contact Person
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Time Period for Report
*
October 1 - December 31, 2025
January 1 - March 31, 2026 & April 1 - June 30, 2026
July 1 - September 30, 2026
October 1 - December 31, 2026
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.
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Enter the total amount sent to provider.
*
Signature
*
Name of Person Submitting Report
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: