Exhibit XXII ADJC Residential Services Invoice.docx
DOCX document 28 KB Posted
- Attached to
- Master Agreement AZ|CTR071448
- Contract number
- CTR071448
- Issued by
- Arizona
About this file
This document is an invoice template for the Arizona Department of Juvenile Corrections (ADJC) Residential Services, designed for contractors providing residential care services. The form is specifically structured for contractors to bill the state agency for services rendered, with a focus on juvenile residential care and behavioral health facilities.
The invoice template covers congregate care (group home) and behavioral health residential services, requiring contractors to detail the full cost, number of juveniles served, units provided, and unit rates. The document includes a certification statement affirming the invoice's accuracy, non-discrimination in service provision, and compliance with potential federal and state audit reviews. While specific pricing is not detailed in this template, it provides a standardized framework for contractors to invoice ADJC for residential services, with the expectation that unit rates are pre-established in the underlying contract.
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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 .