Exhibit XXII ADJC Residential Services Invoice.docx
DOCX document 28 KB Posted
- Attached to
- Master Agreement AZ|CTR071420
- Contract number
- CTR071420
- 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, specifically for congregate care (group home) or behavioral health residential facilities, to invoice the state agency for services rendered to juvenile offenders.
The invoice template allows contractors to detail service units, number of juveniles served, unit rates, and total contract costs. It includes space for contract number, invoice number, purchase order number, service month/year, and contact information. The form requires a certification statement affirming service accuracy, non-discrimination, and completeness, to be signed by an authorized representative. The document was revised on 1/03/23 and provides a standardized billing mechanism for residential juvenile service providers working with the Arizona Department of Juvenile Corrections.
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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 .