Attachment C

SERVICE DELIVERY REPORT (SDR)

The following is an account of activity for services delivered under contract #_________________ for the Department of Public Health for the month of ____________.

************Narrative*************

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CERTIFICATION – The proceeding is a summary of activity that occurred during the month of _______.  The following pages reflect actual expenses for the month/contract, the actual bills are available for review and shall be maintained in accordance with EOHS General Conditions for 6A and 7D.

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  Authorized Signature                                                          Date