r>RDr~.K No. ~.Fyr~~,3
APPOI?~TMb~NT (~F rATHY r-Tf~K`,AN A;=~ THF, r?!~.SI(~NAT'_~.?:~
INDIVIDUAL R}:~iPC?NSI?3LE F(~}"i ^I,A IMIN~~ '~L,IA(' FT.iN~~S
On this T:h~° :>_7th d~iy <,f JtzT.y Tt?~?~ay upon met:i.cyn mi<~tF by
Commissioner M~~r.-g~-rn, sc-~ct~n~led ray C'nrr~miss:i~~ne~r L?al.dwr., the
Court. un.:~n.imously ~ipprc~vc'c i-hr.--~ ~~pZ:>c>int.ment ~f C~t~?-~y Norc~frn,
InC~igent~ He:~ ~t:rl C'ar'e nOOYtilnr~'tOr, ciS t;~iE? t1eS]_CJrtat',P.C~.
indiVid~a~l wir:h over~r'7.1 authority ,~nc:i r'esponsibiJ. ~_ty f_<xr
en:;uring that :iI,IAt3 funds r.l~=~imfacj r,y Kerr c"'o~ant:y ineei; fih~:
est~zk~li.shec3 progr.:arf: req~zirerneni-s.
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:J; .,
JUL 2 ~ REVD
CATHY HORGAN
Kerr County Indigent Health Care Coordinator
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SECTION 6
SLIAG
Page 8
SLIAG Program Administration
Procedures for Claiming SL/AG Funds
Purpose To explain the procedures for claiming SLIAG reimbursement.
esignated ~ Before submitting a claim for SLIAG funds, the county Commissioners
Individual Court must designate, by resolution, an individual with overall authority
and responsibility for ensuring that SLIAG funds claimed by the county
meet the established program requirements.
Form 4116 State law and the state comptroller require that all bills against the state
be paid by voucher. Use Form 4116, State of Texas Purchase Voucher, to
claim SLIAG funds for allowed CIHCP expenditures for ELAs. A copy of
the Commissioners Court resolution designating an individual with
responsibility for SLIAG must be attached to the first Form 4116 submit-
ted. If the Commissioners Court designates another. individual, a copy of
the Commissioners Court resolution designating the newly responsible
individual must be attached to the first subsequent Form 4116 submitted
to DHS. The designated individual must sign all Forms 4116 submitted
to claim SLIAG funds on behalf of the county. Separate instructions for
preparing a Form 4116 for a SLIAG claim are contained in the Forms Sec-
tion of this handbook immediately following Form 4116.
Form 4116 The designated county official must ensure that the following certification
Certification is included on each Form 4116 claiming SLIAG funds:
"For reimbursement for health care services provided and administrative
costs incurred in providing services to Eligible Legalized Aliens under the
State Legalization Impact Assistance Grants (P.L. 99-603, §402).
Procedures for Claiming SLIAG Funds continues on next page
CIHC 89-211VIav 1989
SECTION 6
SLIAG
Page 9
SLIAG Program Administration
Procedures for Claiming SLIAG Funds tconc~nuea)
Form 4116 "I, (designated person), the individual designated by (county name)
Certification County Commissioners Court with overall responsibility foi• claiming
(continued) State Legalization Impact Assistance Grant (SLIAG) funds for said
county, certify that the attached docwnented county program andlor
adnunistrative expenditures correctly and accurately show expenditures
made for Eligible Legalized Aliens (ELAs) through said county's County
Indigent Health Care Program. I further certify; on behalf of said county;
that in submitting this claim for SLIAG funds:
"1. I have read and fully understand the Texas Department of Human
Services Adopted Rules pertaining to SLIAG in relation to the
County Indigent Health Care Program and published in the Texas
Register, and Section 6 of the County Indigent Health Care Program
Handbook, which pertain to SLIAG. This claim for SLIAG grant
funds strictly complies with all definitions, policies. procedures. forms
instructions, and other requirements contained in rule and handbook
materials.
"2. I agree that if an error was made in submitting this claim. said count~~
wiU return to the Texas Department of Human Services any and all
SLIAG funds erroneously claimed and received by said county. The
Texas Department of Human Services is in no way liable for any erro-
neous claims made by said county."
Claims for Each claim for SLIAG funds consists of a
SLIAG Funds Form 4116 completed according to form instructions, and
• documentation of the allowed CIHCP expenditures being claimed for
services provided to ELAs.
Prepare an original and four copies of each SLIAG claim. Retain one copy
for county records.
Procedures for Claiming SLIAG Funds continues on next page
CIHC 89-2llt~Iay 1989