6800 APPENDIX 15 UnitServiceMoReport (DOC-1026).doc
DOC document 64 KB Posted
- Contract number
- 410036-M19-CJO6800-RFB-00
- Issued by
- Wisconsin
About this file
This is a Unit Service Monthly Report form (DOC-1026) used by the Wisconsin Department of Corrections, Division of Community Corrections for reimbursement purposes under Wisconsin Statutes Section 301.08. The form is designed for supplier agencies providing services to correctional offenders to request reimbursement from the state for units of service delivered.
The document serves as a billing mechanism where provider agencies report the specific units of service provided, including unit descriptions, number of units delivered, cost per unit, and total reimbursable amounts. Agencies must submit this form along with an accompanying Offender Monthly Report within 30 days after the month's end for which services were provided. The form requires certification that all claimed services are accurate, have not been previously reimbursed, and comply with Wisconsin Department of Corrections laws, rules, and regulations. The reimbursement structure is based on actual service delivery to eligible correctional offenders under the state's community corrections programs.
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Text version
DEPARTMENT OF CORRECTIONS
Division of Community Corrections
DOC-1026 (Rev. 6/2018)
WISCONSIN
Wisconsin Statutes
Section 301.08
UNIT SERVICE MONTHLY REPORT
DOC USE ONLY:
RECEIVED DATE
RECEIPT NUMBER
SUPPLIER NAME
PURCHASE ORDER NUMBER
INVOICE NUMBER
REMIT TO NAME (If Different than Above) REPORTING PERIOD (Month/Year)
PROGRAM NAME
REMIT TO ADDRESS
As the authorized representative of the above named agency, I request that my agency be reimbursed for units of service provided to eligible Correctional offenders.
UNIT(S) OF SERVICE(S) PROVIDED
| UNIT DESCRIPTION |
| NUMBER OF |
UNITS
COST PER
UNIT
TOTAL
| NET REIMBURSABLE |
| = |
I understand that my agency is required to submit an Offender Monthly Report within 30 days after the final day of the month for which this Unit Service Report is due.
I certify that the unit(s) of service(s) indicated for claiming State reimbursement are just, true and correct in the amount stated and have not been reimbursed, and represent actual services delivered and reimbursable under the laws, rules and regulation of the Wisconsin Department of Corrections.
| PROVIDER AGENCY CONTACT SIGNATURE |
| DATE SIGNED |
DISTRIBUTION: Original – DCC Central Business Office File
File details come from the government source that posted it. Updated .