Vendor Monthly Service Invoice Form - New York, New York

This "Vendor Monthly Service Invoice Form" is a part of the paperwork released by the New York State Education Department specifically for New York residents.

The latest fillable version of the document was released on November 4, 2014 and can be downloaded through the link below or found through the department's forms library.

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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
Print Form
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
Print Form

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