Exhibit XXII ADJC Residential Services Invoice.docx

This document is an invoice template for the Arizona Department of Juvenile Corrections (ADJC) Residential Services contract. The invoice form is designed for contractors providing residential services, specifically for congregate care (group home) or behavioral health residential facilities for juvenile corrections. The template requires detailed information about the contractor, including their name, contract number, invoice details, service type, and contact information.

The invoice template supports billing for residential services with a structured format capturing units of service, number of juveniles served, unit rates, and total invoice amount. Contractors must complete the invoice with specific details about the services rendered, including the month and year of service, number of units provided, and the contracted unit rate. The document includes a mandatory certification statement affirming the accuracy of services, non-discrimination in service delivery, and acknowledgment that the invoice is subject to federal and state audit review. The template was revised on 1/03/23 and requires an authorized representative's signature to validate the invoice.