Interpreting Services Statement
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1
2AOC-INT-1
AP PART IX
Invoice No.
5HY
SECTION 14
Service Date:
Page 1 of 2
___ of ___ (invoice(s) continued)
Certification No. ________________
Commonwealth of Kentucky
S
TATEMENT FOR
[ ]
[ ]
Visual
Spoken
Court of Justice
I
S
NTERPRETING
ERVICES
Language Interpreted ________________________ Dialect of the Language _____________________________
Interpreter’s Name _______________________________
Portal Address
(if different from billing address)
Billing Address __________________________________
_________________________________________
_______________________________________________
_________________________________________
_______________________________________________
_________________________________________
SSN No. or Fed. ID No. ____________________________ Phone Number _____________________________
AOC Internal Use Only Org/ Suborg __________ Function ________ Rept Cat ______ Activity ___________
Subtotal __________________ Miles ___________ Grand Total ______________________
Initials _______
Total # of Cases: __________
[ ] Check if billing for a 24 Hour Cancellation or a No Show
Total Interpreting Time ___________ x $____________ (Uniform Payment Rate) =
$_____________(+)
Total Parking (Attach receipt(s) to Invoice): $_____________(+)
Total Other Expenses (Attach receipt(s) to Invoice) : $_____________(+)
Travel Time and mileage can be billed if traveling outside of your County
Subtotal: $_____________(=)
Total travel time_____._______ X $____________ (Uniform Payment Rate for travel) = $____________(+)
Odometer reading (Start______________ End ______________ )
Total Mileage
= $_____________(+)
$ _________ (cents) x ___________(miles)
GRAND TOTAL: $
(=)
INVOICE(S) SHALL BE SUBMITTED WITHIN 7 DAYS OF THE SERVICE BEING PROVIDED. FAILURE TO
COMPLY WITH THIS REQUIREMENT MAY RESULT IN DELAY.
I hereby state the information provided on this form and the payment requested is true to the best of my knowledge.
Each charge is supported by relevant orders and receipts. NO OTHER INVOICE HAS BEEN SUBMITTED FOR
THESE SERVICES.
Date: ______________, 2______.
_________________________________ Interpreter Signature
Services Continued to________________________ (County Name) and __________________ (Invoice number).
Services Continued from _____________________ (County name) and __________________ (Invoice number).
Team Interpreting _____________________________________________(Name of person you Interpreted with).
VERIFICATION OF APPOINTING/REQUESTING AUTHORITY
[ ] Party(s)
[ ] Witness(es)
[ ] Juror(s) being [ ] deaf/hard of hearing [ ] unable to speak the English
language, and the assistance of an interpreter being required for [ ] court proceeding OR
[ ] direct services to the court/circuit clerk/AOC, the charges incurred in the above case(s) are approved for
payment.
_____________________________________
____________________________________________
Print Name of Requesting Authority
Signature of Appointing/Requesting Authority:
County: ____________________________
[ ] Presiding Judge
[ ] Chief Judge
[ ] Circuit Clerk
[ ] AOC Manager
Date: _____________________, 2_______
[ ] COJ Designee (Title) _____________________
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