Exhibit XXII ADJC Residential Services Invoice.docx
DOCX document 28 KB Posted
- Attached to
- Master Agreement AZ|CTR071428
- Contract number
- CTR071428
- Issued by
- Arizona
About this file
This document is an invoice template for the Arizona Department of Juvenile Corrections (ADJC) Residential Services contract. The form is designed for contractors providing residential services to juvenile corrections, specifically for Congregate Care (Group Home) or Behavioral Health Residential Facility services. The invoice template requires comprehensive documentation from the service provider, including contract number, invoice details, service type, contact information, and billing specifics.
The invoice template allows for billing based on units of service, with contractors required to specify the number of ADJC juveniles served, units provided, and unit rate. The form includes a certification statement affirming the accuracy of services rendered, non-discrimination in service delivery, and acknowledging potential federal and state audit review. While specific pricing is not detailed in this template, it indicates a standardized invoicing process for residential juvenile services with a defined rate structure. The document was revised on 1/03/23, suggesting an active and current contractual arrangement for juvenile residential services in Arizona.
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Text version
EXHIBIT XXII
ARIZONA DEPARTMENT OF JUVENILE CORRECTIONS
RESIDENTIAL SERVICES INVOICE
| CONTRACTOR’S NAME |
| CONTRACT # |
IDENTIFIED INVOICE #
INVOICE DATE
PURCHASE ORDER #
MONTH/YEAR OF SERVICE
CONTRACT SERVICE |_| Congregate Care (Group Home) or |_| Behavioral Health Residential Facility
ADDRESS
CITY
STATE
ZIP
CONTACT PERSON
PHONE
FULL COST UNITS
NUMBER OF ADJC
JUVENILES SERVED
UNITS PROVIDED
UNIT RATE $ (Contract Rate)
SUBTOTAL $
| TOTAL AMOUNT OF INVOICE $ |
The Certification Statement as follows. “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.”
| Authorized representative’s name |
| Signature |
| Date |
Revised 1/03/23
File details come from the government source that posted it. Updated .