Exhibit XXII ADJC Residential Services Invoice.docx
DOCX document 28 KB Posted
- Attached to
- Master Agreement AZ|CTR071415
- Contract number
- CTR071415
- 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 facilities. The invoice template requires detailed information including contractor name, contract number, invoice number, purchase order, and service period.
The invoice template outlines a billing structure based on units of service, with specific fields for the number of ADJC juveniles served, units provided, and unit rate. Contractors must complete the form with their full cost, calculate subtotals, and provide a total invoice amount. A mandatory certification statement requires the authorized representative to affirm the invoice's accuracy, service provision without discrimination, and acknowledgment that the statement is subject to federal and state audit review. The document was revised on 1/03/23 and appears to be a standardized billing instrument for juvenile residential service providers.
View the file
Other files
Show all 32
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .