Invoice for Yard Work

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					                                                                                             Extend-A-Family Association
                                                                                                        91 Moore Avenue
                                                                                              Kitchener, Ontario N2H 3S4
                                                                                                        Ph: 519-741-0190

          SSAH INVOICE/REIMBURSEMENT SHEET FOR INDEPENDENT SERVICE PROVIDERS (ISP)

Individual Supported: __________________________________                  EAF Coordinator: _______________________
Address: ____________________________________________
RESPITE
    Dates of Service                                                               Service Provider
                                # of Hours         Cost
    (month/date/year)                                                Print Name                           Signature




                    TOTALS              hrs.   $

OTHER (Transportation, recreation programs, day/residential camps)
         *NEW - Light housekeeping and/or yard work on an approved temporary and exceptional basis only.
                       Dates of Service                                    Service Provider
 Type of Service                              Cost                 Print Name                Signature
                       (month/date/year)
                                                                                             (*or attach signed invoice/receipt)




                                     TOTAL     $

* Original receipts are required for reimbursement for registration in recreation programs and/or day/residential camps.
Please attach.


__________________________________                 ________________________________                 ___________________
       Family – Print Name                                  Family – Signature                             Date

PLEASE NOTE: Payment will be made via direct deposit for family reimbursement according to the
             Reimbursement Schedule on reverse (unless direct payment arrangements are made).
             No faxed copies will be accepted – originals only.

				
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