Invoice Detail Sheet by HD623H


									                                                                       Invoice Detail Sheet

Host Site:

                                                    Host Organization
                                                   billable expenses for                                          Total for this
Period:                                                 this period                Match for this period             period
Operating Expenses
Site Supervisor Name:
Site Supervisor Benefits:                                                                                                    0.00
On- Site Supplies:                                                                                                           0.00
Travel- site supervisor                                                                                                      0.00
Total Operating Expenses In-Kind Match:                     0                                  0                             0.00

Promise Fellow Expenses

Promise Fellow Name:

Local Travel per Pormise Fellow                                                                                              0.00
TB Testing- per Promise Fellow                                                                                               0.00
Fingerprinting- per Promise Fellow                                                                                           0.00
                                                          0.00                             0.00
                                                         71.27%                           28.73%
Promise Fellow Living Allowance/Stipend for this
period                                                                                                                       0.00
                                                           85%                                15%
FICA                                                                                                                         0.00
Worker's Comp:                                                                                                               0.00
Health Care                                                                                                                  0.00
Total Stipend/Benefits                                               0.00                                  0.00              0.00
                                                                       Host Organization:

                                   City, State, Zip:
                                        Due by the 18th of the Month following the Month expenses are claimed for.

Bill To:
Sonoma State University                                                                                              Date
California Institute on Human Services
Attn: Stephanie Boyd                                                                                            Number of Promise Fellows:
1801 E. Cotati Ave.
Rohnert Park, CA 94928                                                                                    Names of Promise Fellows Billing for in this period:

Program Name
Program Start Date
Grant Number:              03ACHCY12-C73 YEAR 3

Request Number:
Period Claiming For

Host Cash Match for this period:                        Host In-Kind Match for this Period:             Host Organization billable expenses:

       Living Allowance: 0.00                                     Site Supervisor: 0                                         Living Allowance: 0.00

                     FICA: 0.00                           Site Supervisor Benefits: 0                                                    FICA: 0.00

         Worker's Comp: 0.00                                     On-Site Supplies: 0                                           Worker's Comp: 0.00

               Health Care: 0.00                                           Travel: 0                                               Health Care: 0.00

TOTAL CASH MATCH:                   0                  TOTAL IN-KIND MATCH:                 0             TOTAL BILLABLE EXPENSES: 0

Contact Person:                                                                    Tel Number:

E-Mail Address:                                                                    Fax Number:

PROGRAM DIRECTOR                                OR                     FINANCIAL OFFICER                                                     DATE

CIHS Use Only:
                                                                                                                            Acct. Payment Approval:
                                                                                                                                QA791 - 1313 - QA791
Project Mgn Approval
Certification: I certify to the best of my knowledge DATE this report is correct and that all expenditures are for
forth and approved in the Grant Award. I further certify to the best of my knowledge that none of the state fu
to assist, promote, or deter union organizing during the life of the contract, including any extensions or rene

  11/11/2009                                                                                        d350abc8-40a9-4591-b4e2-428b97cac020.xlsInvoice Form
                                       Promise Fellow Service Hour Log

Organization:                                                                                 Month / Year:

Promise Fellow:

Day of Month
                     1    2   3    4    5    6   7    8    9    10   11   12   13   14   15   16   17   18   19   20   21   22   23   24   25   26   27   28   29   30   31
Comm. Strength
Member Dev.

Total Hours
for Day

Weekly Subtotals

Total Hours
for month

Certification: Attendance and absences recorded are accurate, verfied, and/or authorized in accordance
with legal requirements, AmeriCorps Promise Fellow Provisions, and authorized objectives.

Fellows Signature:_________________________                    Date:_____________________________

Supervisor's Signature:_______________________                 Date :____________________________

Name and Title: ______________________________
Invoice Billing:

Invoices Due 18th of the month followng the month expenses were incurred

Include Invoice Detail Sheet with each invoice

Include Monthly Time Log with each invoice

Pre Approved Travel Reimbursements:

Complete Payee Data Record for person who is being reimbursed

Complete Consultant Travel Reimbursemnt form, attaching original receipts

Mail Originals to:

Sonoma State University
CIHS- Attn. Stephanie Boyd
1801 East Cotati Ave
Rohnert Park, Ca 94928

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