Exhibit XXII ADJC Residential Services Invoice.docx
DOCX document 28 KB Posted
- Attached to
- Master Agreement AZ|CTR071419
- Contract number
- CTR071419
- Issued by
- 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 .