Bank Draft Approval
State of Kansas Employee Health Care Program
Non-State Groups
Instructions: Each month this form is to be signed by the county/district director
and the board/governing body chair, treasurer and secretary to approve the bank
draft for the premiums for the State of Kansas Employee Health Care Program for
Non-State Groups. File a copy with the monthly financial records and mail a copy
with the monthly audit information to the K-State Research and Extension
Business Office.
Date________________
County/District_______________________
Employer portion of health insurance premiums
$___________________
Employee portion of health insurance premiums
$___________________
TOTAL
$___________________
Audited and approved as correct, due and unpaid:
Signature of county/district director:________________________________
We authorize a bank draft of $______________________ to the State of Kansas for
the month of __________________________.
Signature of Treasurer___________________________________________
Signature of Secretary___________________________________________
Signature of Chair______________________________________________
KSU 1-12 (4/23/04)