Exhibit_F.xlsx
XLSX spreadsheet 12 KB Posted
- Attached to
- Master Agreement AZ|CTR055722
- Contract number
- CTR055722
- Issued by
- Arizona
About this file
The document is an Exhibit F invoice template for Non-Medical Transportation Broker Services, designed as a standardized billing form for transportation service providers. While the specific template is currently blank, it appears to be a structured document for tracking and billing transportation services, with designated fields for provider details, contract information, service dates, and individual ride specifics.
The invoice template includes columns for capturing critical transportation service details such as rider name, date of service, pick-up and delivery addresses, miles traveled, unit rate, and total amount due. The form includes a legal attestation statement indicating that the invoice represents a true and accurate account of services, provided without discrimination, and subject to potential federal and state audit review. The template is structured to support tracking of urban and rural transportation services under a specific contract number, though no specific contract details are populated in this example.
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Text version
Sheet1
| EXHIBIT F |
| Non-Medical Transportation Broker Services |
| Provider Name: | Invoice #: | Original Invoice: |
| Contact Phone #: | Service Month/Year: |
| Contract Number: | |
| Urban | Date Submitted: |
| Rural |
Provider Signature:
| DATE: | |
| “This invoice is a true and accurate account of the services listed on this statement for the time period specified; this invoice constitutes the full and complete charge for the services described above; that no further invoices | |
| for payment of these services will be made; these services have been provided without discrimination based on age, race, color, creed, gender, religion or national origin and that this statement is subject to | |
| federal and state audit review.” |
| K # | Rider's Name | Date of Service | Pick up Address | Delivery Address | Miles | Unit Rate | Total Due |
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Total: 0 0
File details come from the government source that posted it. Updated .