Coordinator Human Services
Resume:
FINANCIAL INSTITUTION DATA MATCH
REIMBURSEMENT REQUEST
Date:
Remit Payments To:
FEI#:
Address:
Contact Person’s Name & Phone#:
Period for
Reimbursement
Year
Reimbursement Amount
Approved for Payment
First Quarter July-September
20
$
Second Quarter October-December
20
$
Third Quarter January-March
20
$
Fourth Quarter April-June
20
$
Total amount requested: $
Send Invoice to: Department of Human Services
Division of Child Support Services
FIDM Coordinator
2 Peachtree Street NW, 20th Floor
Atlanta, GA 30303
2 Peachtree St. N.W., Atlanta, GA 30303 dhs.ga.gov
Contact this candidate