Exhibit_D_-_PRE-ETS_Service_Summary_and_Invoice.doc
DOC document 90 KB Posted
- Attached to
- Master Agreement AZ|CTR056097
- Contract number
- CTR056097
- Issued by
- Arizona
About this file
This document is an invoice form for Pre-Employment Transition Services (Pre-ETS), specifically designed for contractors providing vocational services, likely through a state agency such as ADES (Arizona Department of Economic Security). The form appears to be a standardized billing document for tracking and invoicing rehabilitation services for students with disabilities, with spaces for contractor details, student information, and service breakdown.
The invoice covers five core Pre-ETS service categories: counseling on post-secondary education, instruction in self-advocacy, job exploration counseling, work-based learning experiences, and workplace readiness training. The form allows for individual or group service tracking, with columns for total sessions attended, contract rate, and total amount billed. Contractors must document workshop details, sub-topics, activities, and materials used, and certify the invoice's accuracy. The document includes provisions for federal and state audit review and requires an authorized signature from the contractor.
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Text version
CONTRACTOR INVOICE FORM
PRE-EMPLOYMENT TRANSITION SERVICES (PRE-ETS)
Billing Period (Month/Day/Year): From , Through ,
| Contract No. |
| ADES17- |
| Invoice # |
| Contractor Name |
| Original |
| FORMCHECKBOX |
| Contractor ID / FEIN# |
| Corrected |
| FORMCHECKBOX |
| Contractor Phone # |
| Contractor FAX # |
| Student Name |
| RSA Authorization # |
FORMCHECKBOX
INDIVIDUAL FORMCHECKBOX
GROUP
| Workshop |
| (A) Total # of Sessions Student Attended |
| (B) Total # of Sessions |
| (C) % of Sessions Attended (A/B) |
| (D) Contract Rate |
| (E) Amount Billed |
| Counseling on Post-Secondary Educ |
| Instruction in Self-Advocacy |
| Job Exploration Counseling |
| Work-Based Learning Experience |
| Workplace Readiness Training |
(F) TOTAL AMOUNT
Describe Workshop Sub-Topics, Activities and Materials Used
COUNSELING ON POST-SECONDARY EDUCATION
INSTRUCTION ON SELF-ADVOCACY
JOB EXPLORATION COUNSELING
WORK-BASED LEARNING EXPERIENCE
WORKPLACE READINESS TRAINING
This invoice is a true and accurate account of the services listed on this statement for the time period specified and constitutes the full and complete charge for the services described above. No further invoices for payment of these services will be made. The services have been provided without discrimination based on age, race, color, creed, gender, religion or national origin. This statement is subject to Federal and State audit review. The invoice has been signed and dated by a person authorized to submit invoices for the Contractor.
Name:
Title:
Email:
Phone Number:
Date:
Signature: ______________________________________________ 3/6/2020 brw
File details come from the government source that posted it. Updated .