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It also affirms that the preparer’s declaration is based on information known to the preparer and warns that false certification may trigger criminal penalties under Illinois law. 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Certification Statement Must Accompany Each Submission of Data)  \nI certify that the application and all information reports, schedules, budgets, books, and records submitted by (provider’s name)  for the cost report beginning   and ending   are true, correct, and accurate in accordance with applicable instructions. Declaration of preparer (other than provider) is based on all information of which preparer has any knowledge. False certification shall be subject to whatever penalties are appropriate under the criminal statutes ofthe State of Illinois.  \nPrepared by:  \nTitle  \n\n| Signature |\n| --- |\n| Name (Typewritten or Printed) |\n\n\n| Firm |\n| --- |\n| Date |\n| Telephone Number |\n\nE-mail Address  \nOfficer or Administrator:  \nTitle  \n\n| Signature |\n| --- |\n| Name (Typewritten or Printed) |\n\n\n| Date |\n| --- |\n| Telephone Number |\n\nE-mail Address","cbCaio8hH8DcJVLb","https://ap.wps.com/l/cbCaio8hH8DcJVLb","pdf",11517,"English","# Certification Statement\n## Provider Certification\n## Prepared By Section\n## Officer or Administrator Section","[{\"question\":\"What does the Illinois Purchased Care Review Board certification statement require you to confirm?\",\"answer\":\"It requires certification that the application and all submitted reports, schedules, budgets, books, and records are true, correct, and accurate for the specified cost report period.\"},{\"question\":\"How is the preparer’s declaration described in the statement?\",\"answer\":\"The preparer’s declaration (other than the provider) is based on all information of which the preparer has any knowledge.\"},{\"question\":\"What information must be provided in the prepared-by and officer/administrator signature sections?\",\"answer\":\"Both sections require signatures and details including typed/printed name, firm (for prepared-by), date, telephone number, and email address.\"}]","Illinois Purchased Care Review Board Certification Statement - Certification Statement for Budgeted and Actual Data | PDF",1791599789]