W. Va. Code R. § 64-116 app. B

Current through Register Vol. XLI, No. 21, May 23, 2024

Appendix B - Post-Fund Distribution Assessment

Responding County Name__________________________ Date Completed_______________

**PLEASE PROVIDE THE FOLLOWING INFORMATION FOR EACH AGENCY IN YOUR COUNTY**

Agency Name__________________________________

Total funding allocated by the county commission to agency pursuant to 64CSR116_________________

Please attach as an addendum the following: Name, Provider Number, and amount of salary supplementation distributed to each emergency medical services provider at each agency in your county.

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W. Va. Code R. 64-116 app B