"Billing Invoice for Interlock Providers" - Nebraska

Billing Invoice for Interlock Providers is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

Form Details:

  • The latest edition currently provided by the Nebraska Department of Motor Vehicles;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Motor Vehicles.

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Download "Billing Invoice for Interlock Providers" - Nebraska

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COMPANY NAME:
INVOICE
STREET ADDRESS:
CITY, STATE, ZIP:
PHONE:
(INVOICE NUMBER BELOW MUST BE A UNIQUE NUMBER)
FAX:
INVOICE NO:
E-MAIL:
DATE:
TO:
FOR:
Department of Motor Vehicles
INTERLOCK INDIGENT FUND
PO Box 94877
Lincoln NE 68509 4877
CLIENT INFORMATION (CLIENT MUST BE PREVIOUSLY APPROVED):
Last, First, MI
Date of Birth
License #
Vehicle Year/Model/VIN:
Type
Installation / Removal and Date of Service:
Total:
Client’s Last Name:
ALR
Court
Installation
Removal
Date
SUBTOTAL
MAINTAINENCE
:
Service Period (Dates):
Client’s Last Name:
Monthly Cost
Funds Requested
From
To
$
$
$
$
$
$
$
$
$
$
SUBTOTAL $
SUBTOTAL FROM ABOVE $
GRAND TOTAL $
FOR DEPARTMENT USE ONLY
Approved by:
Date:
EFFECTIVE 01/01/2012
COMPANY NAME:
INVOICE
STREET ADDRESS:
CITY, STATE, ZIP:
PHONE:
(INVOICE NUMBER BELOW MUST BE A UNIQUE NUMBER)
FAX:
INVOICE NO:
E-MAIL:
DATE:
TO:
FOR:
Department of Motor Vehicles
INTERLOCK INDIGENT FUND
PO Box 94877
Lincoln NE 68509 4877
CLIENT INFORMATION (CLIENT MUST BE PREVIOUSLY APPROVED):
Last, First, MI
Date of Birth
License #
Vehicle Year/Model/VIN:
Type
Installation / Removal and Date of Service:
Total:
Client’s Last Name:
ALR
Court
Installation
Removal
Date
SUBTOTAL
MAINTAINENCE
:
Service Period (Dates):
Client’s Last Name:
Monthly Cost
Funds Requested
From
To
$
$
$
$
$
$
$
$
$
$
SUBTOTAL $
SUBTOTAL FROM ABOVE $
GRAND TOTAL $
FOR DEPARTMENT USE ONLY
Approved by:
Date:
EFFECTIVE 01/01/2012