Exhibit_D_-_PRE-ETS_Service_Summary_and_Invoice.doc
DOC document 90 KB Posted
- Attached to
- Master Agreement AZ|CTR056087
- Contract number
- CTR056087
- Issued by
- Arizona
About this file
This document is a contractor invoice form for Pre-Employment Transition Services (Pre-ETS), specifically designed for documenting and billing service delivery. The form appears to be associated with a state agency contract, likely related to vocational rehabilitation services, with a contract number format of ADES17-. The document provides a structured template for contractors to detail services provided to students with disabilities, including workshop and service tracking.
The invoice form covers five core Pre-ETS service categories: Counseling on Post-Secondary Education, Instruction in Self-Advocacy, Job Exploration Counseling, Work-Based Learning Experience, and Workplace Readiness Training. The form allows contractors to document individual or group workshop sessions, tracking the total number of sessions attended, percentage of attendance, contract rates, and total amount billed. The document includes space for detailed descriptions of workshop sub-topics, activities, and materials used, and requires certification by an authorized contractor representative that services were provided without discrimination and are subject to federal and state audit review.
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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 .