Exhibit XXII ADJC Residential Services Invoice.docx
DOCX document 28 KB Posted
- Attached to
- Master Agreement AZ|CTR071425
- Contract number
- CTR071425
- Issued by
- Arizona
About this file
This document is an invoice template for the Arizona Department of Juvenile Corrections (ADJC) Residential Services contract, specifically designed for service providers to bill for residential care and behavioral health services provided to juvenile populations. The template is issued by the state of Arizona and is intended for use by contracted residential service providers who work with the juvenile corrections system.
The invoice template allows contractors to document services across two primary service categories: Congregate Care (Group Home) and Behavioral Health Residential Facility. The form captures critical billing details including contract number, invoice number, service units, number of juveniles served, unit rates, and total invoice amount. Contractors must complete a certification statement affirming service accuracy, non-discrimination, and agreement that the invoice represents a complete and true account of services rendered. The document was last revised on 1/03/23, indicating ongoing refinement of the state's procurement and billing processes for juvenile residential services.
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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 .