Vendor Monthly Service Invoice Form - New York, New York

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Impartial Hearing Order Implementation Unit
Division of Specialized Instruction and Student Support
VENDOR MONTHLY SERVICE INVOICE FORM
CASE INFORMATION
Case Number: ____________________
Service Period: Month __________ Year __________
Today’s Date: __________________
Service Type: ____________________
Service Location: _____________________________
Invoice Number: _______________
STUDENT INFORMATION
Name: _________________________________________________________
Student ID/OSIS #: _______________________
Home Address: ___________________________________________________________________________________________________________
AGENCY/INDEPENDENT PROVIDER INFORMATION
Name: _________________________________________________________________
EIN #/SSN #: ____________________________
Address: ________________________________________________________________________________________________________________
Email Address: ________________________________________________________
Telephone Number: (______) _______ - __________
Service Provider Name (FOR AGENCIES ONLY): _____________________________________________________________________________
DATE OF
LENGTH OF
DATE OF
LENGTH OF
DATE OF
LENGTH OF
SESSION TIME
SESSION TIME
SESSION TIME
S ERVICE
SESSION
S ERVICE
SESSION
S ERVICE
SESSION
Total Number of Hours: _______________
Rate Per Hour: $________________
Total Amount Due: $________________
I hereby certify that I have provided services on the dates for the duration indicated herein. I understand that when completed and filed, this form
becomes a record of the NYC Department of Education (DOE) and is relied upon by the DOE to make payment and any material misrepresentation may
subject me to criminal, civil, and/or administrative action.
Provider Full Name (please print): ___________________________________________________________________________________________
Provider Signature: _______________________________________________________________________
Date: _____________________
By my signature, I acknowledge that I have reviewed this billing form and that, to the best of my knowledge, these sessions were provided as indicated.
FOR SERVICES PROVIDED AT HOME:
FOR SERVICES PROVIDED AT SCHOOL:
Parent Full Name (please print): _____________________________
Principal Full Name (please print): ___________________________
Parent Signature: _________________________________________
Principal Signature: _______________________________________
Date: __________________________________________________
Date: ___________________________________________________
Submit original invoices to:
New York City Department of Education
Impartial Hearing Order Implementation Unit
65 Court Street - Room 1503
Brooklyn, New York 11201
ATTN: Barbara Thorpe
PLEASE NOTE: FAILURE TO COMPLETE ALL FIELDS MAY RESULT IN THE DELAY OF PAYMENT.
rev. 4/11/2014
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