Attachment_4_-_Sample_Invoice_and_Modification_Form.pdf
PDF 227 KB Posted
- Attached to
- SHF | 2026-08 Housing and Navigation Services
- Solicitation number
- SFGOV-0000012217
- Issued by
- San Francisco County, San Francisco City, California
About this file
This document is a sample invoice and budget modification form from the San Francisco Sheriff's Office (SFSO) Programs Division for use with grants and contracts during fiscal year 2024-2025. The Monthly Expenditure Summary Report template is designed to track program expenditures across multiple budget categories including Salaries and Fringe, Operating Expenses, Sub-Contractual Services, Equipment Purchases, and Administrative/Indirect Costs. The form requires monthly reporting with columns for Approved Budget, Expended This Month, Year-to-Date expenses, and remaining Balance. The invoice references a grant period from July 1, 2024 through June 30, 2025, and notes insurance expiration dates for General/Auto coverage (April 1, 2025) and Workers' Compensation (January 1, 2025). The form includes sections for program staff to prepare invoices and for SFSO Finance to review, approve, and process payments, with designated spaces for tracking advance payments, adjusted payment amounts, receipt IDs, voucher IDs, and payment dates.
The Budget Modification Request Form section allows agencies to propose changes to their Approved Budget allocations across the same expense categories, requiring written justification and documentation of how modifications impact program design or scope. All budget modifications require authorization signatures from both the Agency Director or Financial Officer and approval from both the Sheriff's Programs Director and the Sheriff's Chief Financial Officer. The document provides a template structure with line items for proposed changes and revised allocations but contains no completed financial data, as all budget amounts and expense categories are left blank in this sample version. This form is intended for use by agencies administering Housing, Expungement and Recovery through Treatment & Support Services (HEARTSS) programs serving criminal justice-involved adults with substance use disorder and/or mental health issues in San Francisco.
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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 |
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