10848_ITN_Exhibit 1_Invoice.pdf

1Assigned by the Provider or use the Contact number/2-digit month/2-digit year format. For example, the invoice number for March 2011 for contract X1234 would be “X1234/03/11”. The invoice number must match the number on the “Summary of Contractual Services Agreement/Purchase Order” form.

2Goods/Services have been satisfactorily received and payment is now due. Revised 8/23/11

EXHIBIT 1

FLORIDA DEPARTMENT OF JUVENILE JUSTICE

INVOICE FOR FIXED PRICE OR FIXED FEE CONTRACT/GRANT

SECTION I:

Provider (Payee) Name: Contract/Grant No.:

Remittance Address: 1Invoice Number:

Program Name: Invoice Date:

Service Address: Service Period From:

FEID#: Service Period To:

SECTION II:

A B C D E

Unit of Service or Description Total Number of Units Total Number of Days Unit Cost Total Cost

Payment Amount Requested

SECTION III:

CERTIFICATION

I certify that the expenditures incurred under this contract/grant are for commodities or services, which are reasonable, necessary, allowable and allocable, and the expenditures directly relate to the purpose of the contract/grant.

I certify that the services this individual or entity have provided services in accordance with the terms and conditions specified in the contract/grant.

I certify that this individual or entity, in accordance with the terms and conditions specified in the contract/grant, maintains any documents and proof of payment supporting the expenditures.

Signature of Provider Agency Official Type or Print Name & Title Telephone & Ext. Date

SECTION IV:

FOR DEPARTMENT USE ONLY

Date Invoice Was Received

Date Goods Or Services Were Received

2Date Goods Or Services Were Inspected And Approved

SIGNATURE & TITLE Of Person Approving Invoice For Payment

PRINT Name Of Person Approving Invoice Telephone # Signature/Date

Org Code Exp Option Object Code Amount Org Code Exp Option Object Code Amount

1. $ 4. $

2. $ 5. $

3. $ 6. $