Exhibit_I_-_PRE-ETS_COORDINATION_OUTCOMES_Summary___Invoice_.doc
DOC document 76 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) Coordination Outcomes, designed for tracking and billing services related to student enrollment and service coordination. The form appears to be a standard template for a state or federal vocational rehabilitation program, with provisions for documenting coordination outcomes and invoicing for services provided to students with potentially eligible status.
The invoice establishes specific payment units for coordination outcomes, including $700 per school enrollment in the Pre-ETS program and $175 for every five non-duplicated potentially eligible students who apply for services during a billing month. The document provides a structured format for contractors to list enrolled schools, individual students served, and total amounts billed, with an emphasis on tracking and verifying service delivery. The invoice requires authorization, includes spaces for contractor identification, and mandates certification by an authorized 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)
COORDINATION OUTCOME SUMMARY & INVOICE
Billing Period (Month/Day/Year): From , Through ,
| Contract No. |
| CTR |
| Invoice # |
| Contractor Name |
| Original |
| FORMCHECKBOX |
| Contractor ID / FEIN# |
| Corrected |
| FORMCHECKBOX |
| Contractor Phone # |
| Contractor FAX # |
| RSA Authorization # |
10.0 Payment Unit
10.4 One School Coordination Outcome is a payment of $700.00 for each high school enrolled into the Contractor’s Pre-ETS program.
10.5 One Student Coordination Outcome is a payment of $175.00 for every five (5) non-duplicated Potentially Eligible Students who apply for Pre-ETS services during a billing month.
| COORDINATION OUTCOMES |
| Number of Outcomes Met |
Unit Rate
Amount Billed
| School Coordination |
| 700.00 |
| Student Coordination |
| 175.00 |
TOTAL AMOUNT
List individual schools enrolled into the Pre-ETS Program SCHOOL COORDINATION OUTCOME (List initial student(s) that has/have completed Pre-ETS with the school enrolled for verification of coordination.)
LIST OF NON-DUPLICATED STUDENTS (List Student Names and dates of completed Pre-ETS Services)
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: ______________________________________________ 3/10/20 smm • 3/12/20 brw
File details come from the government source that posted it. Updated .