Attachment_4_-_Sample_Invoice_and_Modification_Form.pdf
PDF 227 KB Posted
- Attached to
- SHF | 2026-06 Medi-Cal Enrollment Services
- Solicitation number
- SFGOV-0000012057
- Issued by
- San Francisco County, San Francisco City, California
About this file
This file is a sample invoice and budget modification form template provided by the San Francisco Sheriff's Office (SFSO) for grant-funded programs operating during fiscal year 2024-2025. The monthly expenditure summary report document is designed to track financial activities for programs with a grant period running from July 1, 2024, through June 30, 2025. The form accommodates multiple budget categories including salaries and fringe benefits, operating expenses, sub-contractual services, equipment purchases, and administrative or indirect costs. The template includes designated sections for tracking approved budgets, monthly expenditures, year-to-date spending, and remaining balances, along with signature lines for authorization by program staff, SFSO finance personnel, and supervisory officials. The document also incorporates an accompanying budget modification request form that allows agencies to propose changes to approved allocations and justify the rationale for such modifications, requiring approval from both the Sheriff's Programs Director and Chief Financial Officer.
The invoice form is structured to facilitate vendor payment processing, with specific fields for advance payment deductions and adjusted payment calculations. The template includes notation for insurance coverage expiration dates, including general liability and workers' compensation policies. The budget modification section requires agencies to specify proposed changes across all expense categories and detail how modifications impact program design or scope. While no specific pricing terms or funding amounts are listed in this template document, the form establishes the administrative framework through which SFSO programs document expenditures and request budget adjustments, serving as the standard accounting tool for grant-funded initiatives operating under Sheriff's Office oversight.
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Text version
SFSO MONTHLY EXPENDITURE SUMMARY REPORT
Invoice No. Invoice Month: July-24 SFSO Use Only:
FSP PO#: 0000XXXX Reviewed By:
Contract ID: 10000XXXX
RFP: SHF 20XX-00 Approved By:
Program Title: Grant Period: Notes:
7/01/2024 - 06/30/2025
Insurance Expires - Gen-Auto (04-01-2025) WC - (01-01-2025)
Program Budget Categories Approved Budget Expended This Month Year-to-Date Balance
Salaries & Fringe*
Subtotal Salaries & Fringe: -$ -$ -$ -$ Operating Expenses
Subtotal Operating Expenses: -$ -$ -$ -$ Sub-Contractual Services
IT Managed Services -$ -$ -$ -$ Database Development -$ -$ -$ -$
Equipment Purchase
0 -$ -$ -$ -$ Subtotal Equipment Purchase: -$ -$ -$ -$
Administrative/Indirect Cost
Subtotal Administrative/Indirect Cost: -$ -$ -$ -$
TOTALS: -$ -$ -$ -$
INVOICE TOTAL -$
Less Advance (if any) -$
ADJUSTED PAYMENT -$
Prepared By: _______________________________________ Date: ____________________
Date: ____________________
FOR SHERIFF USE ONLY:
Date Received: ________________ ______________
Invoice Received By (Initials): ___________ Finance Approved by: ____________________________
Date Invoice Processed: ________________ Payment Amount: _____________________
Receipt ID: _______________________________ Payment Date: _________________________
Voucher ID : ______________________________ Reference #: ___________________________
Subtotal Equipment Purchase:
Rent
Program Materials/Supplies:
Office Supplies Printing Educational/Training Materials
Client Support (e.g., hygiene kits)
Vendor & Payment Date Verified:
Approved By: ______________________________________
Indirect Cost - 20%
Supplier ID / Vendor Name:
00000XXXX
Salaries & Fringe**
Client travel (public transportation)
Program Staff Travel (Local & Out of Town) Other (describe):
Postage
Program Staff Training Utilities Office Equipment Lease Office Equipment/IT/ Cell Phones
SFSO (rev 2024) SAN FRANCISCO SHERIFF'S OFFICE Program Invoice Form
Agency Name:
Program Title:
Grant Number: Date of Request:
Grant/Contract Period: Modification #:
Program Expense Item: Approved Budget Proposed Changes Revised Allocation
Budget
A) Salaries & Fringe Benefits -$ -$
B) Direct Program Operating Expenses -$ -$
C) Sub-Contract Services -$
D) Equipment Purchases -$ -$
X) Administrative/Overhead (Indirect) -$
Grand Total: -$ -$ -$
10. Justification for Budget Modification
11. How does the modification impact the design or scope of the program?
Authorized Signature of Agency - Director or Financial Officer Date:
Approval of Budget Modification:
(Sheriff's Programs Director) Date:
(Sheriff's Chief Financial Officer) Date:
San Francisco's Sheriff's Office Programs Division
FY 2024-2025 Budget Modification Request Form
Budget Modification Summary
Approval of Budget Modification Sheriff Use Only
SFSO (rev 2024)
Budget Modification
| invoce |
| Budget Mod form |
File details come from the government source that posted it. Updated .