Exhibit XXII ADJC Residential Services Invoice.docx
DOCX document 28 KB Posted
- Attached to
- Master Agreement AZ|CTR071445
- Contract number
- CTR071445
- 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 Congregate Care (Group Home) or Behavioral Health Residential Facility services to juvenile corrections clients. The invoice template requires detailed documentation from the contractor, including contract number, invoice number, service type, location, contact information, and service units.
The invoice template outlines a billing process for residential services with specific provisions for tracking units of service, unit rates, and total invoiced amounts. Contractors must provide the number of ADJC juveniles served, units provided, and the contracted unit rate. The document includes a certification statement requiring contractors to affirm the invoice's accuracy, service provision without discrimination, and acknowledging potential federal and state audit review. The template was revised on 1/03/23 and provides a structured approach for contractors to bill the Arizona Department of Juvenile Corrections for 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 .