Appendix 8 DOC-1026 Unit Service Monthly Report.doc
DOC document 64 KB Posted
- Contract number
- 410036-M20-CJO7250-00
- 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 to process reimbursement requests from supplier agencies providing services to correctional offenders. The document operates under Wisconsin Statutes Section 301.08 and involves supplier agencies, the Wisconsin Department of Corrections, and correctional offenders as the end beneficiaries of services.
The form facilitates reimbursement for units of service provided to eligible correctional offenders, with fields for unit descriptions, quantities, cost per unit, and total net reimbursable amounts. Supplier agencies must submit this report along with an Offender Monthly Report within 30 days after the final day of each reporting month. The authorized representative must certify that the claimed services are accurate, have not been previously reimbursed, represent actual services delivered, and comply with Wisconsin Department of Corrections laws, rules, and regulations. The form requires supplier information, purchase order numbers, invoice details, and remittance addresses for processing payments through the DCC Central Business Office.
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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 .