Exhibit_G_-_Contractor_Invoice_Form.pdf
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- Attached to
- Master Agreement AZ|CTR058022
- Contract number
- CTR058022
- Issued by
- Arizona
About this file
This document is a Contractor Invoice Form for a Rehabilitation Services Administration (RSA) contract involving small business consultation services. The form appears to be associated with a state agency, likely the Arizona Department of Economic Security (ADES), and is designed for contractors providing vocational rehabilitation (VR) services to clients.
The invoice form outlines unit rates for services provided in local and distant counties, with billing based on hourly rates for face-to-face consultations and business plan reviews. Services are billable in 15-minute increments, with rates rounded to the nearest quarter-hour. The contract specifies that unit rates are all-inclusive, covering costs such as interpretation, salaries, travel, preparation, and research time. Contractors must not exceed the authorized number of units specified in the RSA Purchase Authorization, and any additional hours require prior written approval from a VR Counselor and Supervisor. The form provides a standardized method for contractors to bill for small business consultation services across different county jurisdictions.
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Text version
Contractor Invoice Form
Actual Service Dates (Month/Day/Year):
Begin Date: / / End Date: / /
Invoice # Original Invoice Contractor’s name: Corrected Invoice Contractor’s Phone Number: Contractor’s Fax Number:
Contract Number: Contractor’s FEI or SSN Number:
RSA client’s name: RSA Authorization Number:
11.1 The Contractor shall provide Unit rates as follows:
11.1.1 One (1) Hour of services provided in a Local County.
11.1.1.1 Local County is /are determined to be those counties where a business has a legal address or any physical location that is owned, leased, or rented, in whole or in part, by the business.
11.1.2 One (1) Hour of services provided in a Distant County
11.1.2.1 Distant County is/are determined to be those counties where the business does not have a legal address or any physical location that is owned, leased, or rented, in whole or in part, by the business.
11.2 One Hour equals sixty (60) minutes of actual time spent providing face to face services specified in Section 6.0 to one (1) VR Client or VR Counselor to discuss specific issues pertaining to the VR Client.
11.3 One Hour equals sixty (60) minutes of actual time spent completing a review of the Business Plan as specified in Section 7.0.
11.4 Billable time includes time spent providing services that last fifteen (15) minutes or more.
11.5 The hourly rate(s) shall be rounded to the nearest quarter of an hour (i.e., fifteen (15) minutes).
Examples: 22 hours and 15 minutes = 22.25 hours; 22 hours and 6 minutes = 22.0 hours; 22 hours and 30 minutes = 22.5 hours; 22 hours and 39 minutes = 22.75 hours; 22 hours and 45 minutes = 22.75 hours.
11.6 Unit rates are all inclusive, which means that they include all costs associated with the provision of the service including but not limited to: foreign and sign language interpretation, salaries, operating cost, travel time, mileage, preparation of billing and reports, routine follow-up phone calls, research time, time for VR Client no shows, etc. RSA will not pay separately for these or any other costs except as noted herein.
11.7 Contractor shall not exceed allotted number of authorized units specified on RSA Purchase Authorization.
ADES may authorize additional hours; however written approval shall be made in advance by the VR Counselor. The authorization for the additional hours is dependent on the VR Client’s service needs and requires prior written confirmation from the VR Counselor and the VR Counselor’s Supervisor. The SERC Facilitator’s written approval shall be obtained for additional hours for consultation and advice services to the RSA self-employment review committee.
Payment requirements from the contract:
SERVICE COUNTY NUMBR OF
HOURS
RATE PER
HOUR
AMOUNT
Small Business Consultation
Local
Small Business Consultation
Distant
TOTAL AMOUNT BILLED
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. These 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. By signing this invoice, the person confirms that they are authorized to submit invoices for the Contractor.
Name, title, email address and phone number of the Contractor’s designated person who prepared this form.
Name/Title: ____________________________________________________________________________
Email:__________________________________________________________________________________
Phone Number:
Signature: _________________________________________________ Date: _______________________
| Actual Service Dates (Month/Day/Year): |
| Payment requirements from the contract: |
| Original Invoice: |
| Corrected Invoice: |
| NUMBR OF HOURSLocal: |
| RATE PER HOURLocal: |
| AMOUNTLocal: |
| NUMBR OF HOURSDistant: |
| RATE PER HOURDistant: |
| AMOUNTDistant: |
| AMOUNTTOTAL AMOUNT BILLED: |
| Invoice Number: |
| Contractor Name: |
| Contractor Phone Number: |
| Contractor Fax Number: |
| Contract FEI or SSN Number: |
| Contract Number: |
| RSA Client Name: |
| RSA Authorization Number: |
| Begin Date: |
| End Date: |
| Name and Title: |
| Email: |
| Date Signed: |
| Phone Number: |
File details come from the government source that posted it. Updated .