Placement Invoice Template - DOC by zkw72695

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									Vendor Name and Address                                                                                                       ADP Vendor Invoice

Vendor Information
ADP Vendor Registration Number
ADP Vendor Name

Invoice Information
ADP Claim Number
Vendor Invoice Number                                                      Invoice Date (yyyy/mm/dd)             _____/___/___

Client Information
Client Health Number                                                       Version:
Client Name (Last Name, First Name)
Client Address
Benefit Program                                    Check      one only:
                                                          Ontario Works Program (OWP)                  Ontario Disability Support Program (ODSP)
                                                          Assistance to Children with Severe Disabilities (ACSD)

Equipment Specifications
Device               ADP                  Description of Item                      Serial         Quantity     Unit        Total        ADP             Client
Placement            Catalogue            (Make & Model)                           Number                      Price       Price        Portion         Portion
(Left, Right, N/A)   Number




                                                                                                       Invoice Totals
Proof of Delivery
I hereby confirm that I have received the equipment described above and that I have received a fully itemized invoice from the vendor for the devices
described above.

Client Signature                                                                   Date of delivery (yyyy/mm/dd): _____/___/___


Ministry of Health and Long-Term Care
Financial Management Branch
49 Place d'Armes, 2nd Floor
Kingston, ON, K7L 5J3

								
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