DHS 0126 Services Report and Invoice- Cost Reimbursement ...
|[pic] |Services Report and Invoice |
| |Cost Reimbursement Payment Request |
| |
| | | |
|Service provider | |Grant agreement number |
| | | | |
|Billing address |City |State |ZIP code |
| | | | |
| | | | |
|Service invoice billing cycle |
|Monthly service dates | |Quarterly services period |
|From: |
|A. |Expenditures |Total DHS billing for current quarter |
|1. |Program — personal services (salaries and benefits) | |
|2. |Program — services and supplies | |
|3. |Program — other expenses | |
|4. |Administrative and indirect costs | |
|Total reimbursable funds for this invoice |0[pic]$0.00 |
| |
|B. |Certificate |
| | | | |
| |Prepared by (please print) | |Phone |
| | |
| |Authorized by |
| | | | |
| |Signature | |Date |
| | | |
| |Printed name | |
| | | |
|Please read instructions on last page carefully |
|Detail narrative (attach additional documentation if necessary) |
| | | |
|Description | |Billed to DHS |
|1. |Personal services: Salaries and benefits related to program services. | | |
| |Hours and wage for facilitating and training, staff | | |
| |time, etc. (If claiming salary please list number of hours per staff member and hourly| | |
| |breakdown of personal costs) | | |
|2. |Services and supplies: Report services, copy costs and other materials. | | |
| |This includes trainings (list dates), transportation, supplies/materials for | | |
| |implementation. | | |
|3. |Other expenses: | | |
| |Miscellaneous expenses (be specific). | | |
|4. |Administrative overhead and indirect costs: | | |
| |(list percentage and provide a brief explanation) | | |
| |
|Form instructions |
|Who must complete: |
|All recipients of the My Future-My Choice program funds awarded through a State of Oregon Grant Agreement to perform My Future-My Choice services. Recipients are |
|responsible for assuring that each report is completed accurately, signed and submitted in a timely manner. |
| |
|Where to submit: |
|Email a signed and scanned form and back up documents to your My Future-My Choice Program Specialist; |
|OR submit original to: My Future-My Choice Program, DHS Youth Services Programs, 500 Summer St. NE, E-48, Salem, OR 97301 or; Invoice can also found on the My |
|Future-My Choice website. |
|Please do not do BOTH and be sure to use the most current version of this form. |
| |
|When to submit: |
|Quarterly (or biannual) invoices are due 25 days following the end of the 3, 6, and 9-month periods and 30 days after the 12-month period. Recipient will identify|
|which reporting schedule for the entire contract period. |
|Instructions for completion |
|Line 1 |Program - Personal Services: Report salaries related to program services. Since payroll expenses may vary from month to month, an approximate amount |
| |may be listed for each reporting period except the final period. Exact yearly cost must be reported. Federal guidelines (OMB Circular A-87 and OMB |
| |Circular A-133) require the maintenance of adequate time-activity reports for individuals paid from grant funds. |
|Line 2 |Program — Services and Supplies: Report program services such as teen and adult training expenses and program supplies. |
|Line 3 |Program — Specific other program expenses |
|Line4 |Administrative Overhead and Indirect Costs: Report expenses not directly chargeable as program costs. List percentage used/how cost was determined. |
|The detail narrative (page 2 of this form) with explanation of expenditures must be included with |
|all invoices submitted. |
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