Exhibit_D_-_PRE-ETS_Service_Summary_and_Invoice.doc
DOC document 90 KB Posted
- Attached to
- Master Agreement AZ|CTR056121
- Contract number
- CTR056121
- Issued by
- Arizona
About this file
The document is a contractor invoice form for Pre-Employment Transition Services (Pre-ETS), specifically designed for tracking and billing vocational support services. While the specific state agency is not fully named, the document appears to be associated with ADES (likely Arizona Department of Economic Security), with a contract number format of ADES17-.
The invoice form is structured to document Pre-ETS service delivery across five key areas: counseling on post-secondary education, instruction in self-advocacy, job exploration counseling, work-based learning experiences, and workplace readiness training. The form enables contractors to detail individual or group workshop sessions, tracking metrics such as total sessions attended, percentage of sessions completed, and corresponding billing rates. The document includes spaces for capturing student details, service specifics, and requires an authorized signature certifying the accuracy of services rendered without discrimination, with the understanding that the invoice is 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 .