The C-13 is a multi-part forms set. The standard entries include:
- case name;
- case ID number - category, county/district, group, and basic (including the PE if appropriate);
- item or service provided;
- signature for the "Certification of Receiving Agency";
- date of service or purchase; and
- Item 10 for supportive service payment approved for work and training activities.
The C-13 must also contain:
- the Federal Employer's Identification Number (FEIN), if payment is to be made to an agency or organization; or
- the Social Security Number (SSN), if payment is to be made to an individual.
Forms submitted without the FEIN or SSN will be rejected and returned for correction.
The Sellers Certification must be signed on the original page when the C-13 is for a tangible item. A signature is not needed when the C-13 is for a service and a bill is included showing the type of service performed and the charges.
Only clients getting the same type of aid can be on one C-13. For example, if a vendor provides the same type of service to 2 TANF clients on the same day, only one C-13 is needed showing both clients and the combined charges for the
2. The total amount will be sent in one check. If one was an AABD client and the other a TANF client, 2 separate C-13s would be needed and 2 checks issued.
Distribute the C-13:
- white - Bureau of Fiscal Operations
- goldenrod - Bureau of Fiscal Operations
- buff - Bureau of Fiscal Operations
- canary - Bureau of Fiscal Operations
- blue - Family Community Resource Center file
- green - vendor.
Additional instructions for specific situations include:
Examination to Determine Medical Condition (AABD and TANF)
Enter the name and address of the provider conducting the exam in the block designated for vendor identification. Enter the type of exam, reason for referral, and net charge for the exam. If charges in addition to the exam fee are made, show the
additional procedures and the charges for each. Show mileage or other travel expenses if travel expenses are being approved.
Examination to Determine Blindness (AABD)
Follow instructions for determining medical condition and write "Determination of Eligibility for Blind Assistance" in the area describing the services provided.
Attach the billing document from the provider performing the exam to the original C-13 submitted for payment.
NOTE: Do not submit C-13 until the supervising ophthalmologist's report has been received.
Payment After Client's Death
When services are provided but the client dies before the payment is approved, a supporting billing document must be submitted with the C-13 sent to the Bureau of Fiscal Operations.
NOTE: If the services are included in the aid check, but death occurs before the check is cashed, no supporting documents are needed.
Training expenses for items not allowable in the regular check are paid directly to the vendor. Enter:
- vendor and client identifying information,
- description of each item or service provided, including charges, and
- appropriation number 2608.
For GA, when payment is for child care or other supportive services, make sure the correct Form 552 Item 80 Needs Code and designator are included on the C-13 (see WAG 27-80-03-c)
Payment for Emergency Shelter
Use code 612, Emergency Shelter, to approve payment to the Salvation Army Lodge in Chicago for emergency shelter.
Office Visit and Lab Test to Determine Pregnancy
Enter in the block designated for vendor identification the name and address of the medical provider conducting the pregnancy test. Enter the client's name, address, and case number. Write "Charges for Pregnancy Test".
NOTE: HFS pays only for the office visit and lab test to determine pregnancy.
Attach the bill from the provider to the C-13 before submission for payment.
Child Care Payment to Provider When a Client Cannot Sign a Redirected Child Care Check
Use C-13 to pay a child care provider when a redirected check is received by the provider but the client is no longer available to sign the check and pay the provider. Use the child care Item 80 code and designator used on the original child care
mercury authorization to approve payment by C-13 (codes 760 through 767 and appropriate 4-digit designator).