Form Dpa 302 Interpreter/translator Billing

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INTERPRETER/TRANSLATOR BILLING
CDSS USE ONLY
INTERPRETER/AGENCY:
Please complete and submit top 3 copies to:
INVOICE
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES (CDSS)
INDEX CODE
I
I
I
STATE HEARINGS DIVISION
LEGAL DIVISION
744 P STREET, MS 9-17-37
744 P STREET, MS 8-5-161
OBJ
PCA
418
4
SACRAMENTO CA 95814
SACRAMENTO CA 9581
NAME OF INTERPRETER/TRANSLATOR
SOCIAL SECURITY NUMBER/FEDERAL ID NUMBER
DATE OF SERVICE
NAME OF AGENCY
ADDRESS
I hereby declare under penalty of perjury that I faithfully and
accurately interpreted/translated from the English language to
CITY
the
language and/or from the
language to the English language for
I
STATE
ZIP CODE
CHECK IF NEW ADDRESS
this assignment.
TELEPHONE NUMBER
SIGNATURE ____________________________________________________________
COMPLETE FOR TRANSLATION SERVICES
COMPLETE FOR INTERPRETATION SERVICES
CLAIMANT
HEARING NO.
CLIENT AGENCY
CONTRACT
HEARING SITE (COUNTY)
LANGUAGE
PROJECT TITLE
SCHEDULED HEARING DATE
ARRIVAL TIME
SCHEDULED START TIME
ACTUAL START TIME
PROJECT DESCRIPTION
STOP TIME
DEPARTURE TIME
MILES ROUND TRIP
LANGUAGE SKILLS USED
REFERENCE
MILES ROUND TRIP
NUMBER OF ROUND TRIPS
I
I
YES
NO
C D S S U S E O N L Y - - D O N O T W R I T E I N T H I S S E C T I O N
________ Total Time
________Miles _____ ¢ per mile
$
____ Translation $ _______ Editing
$ _______ Input
$ _________ First Hour
$ _________Mileage Fee
____ Miles at _______ ¢ per miles $ _______ Mileage Fee
$ _________ Add’L Hrs
$ _________Parking (attach receipt)
Total Fee $ ________
Total Fee $ ________
SIGNATURE AND APPROVAL BY
DATE
VERIFIED BY AUTHORIZED COUNTY/CDSS STAFF
DATE
IMPORTANT INFORMATION
The Interpreter/Translator Contractor named herein agrees to indemnify, defend and save harmless the State, its officers, agents and employees from
any and all claims and losses accruing or resulting to any and all contractors, subcontractors, materialmen, laborers and any other person, firm or
corporation furnishing or supplying work services, materials or supplies in connection with the performance of this contract, and from any and all claims
and losses accruing or resulting to any person, firm or corporation who may be injured or damaged by the Contractor in the performance of this contract.
The Contractor, and the agents and employees of Contractor, in the performance of the agreement, shall act in an independent capacity and not as
officers or employees or agents of the State of California.
The State may terminate this agreement and be relieved of the payment of any consideration to Contractor should Contractor fail to perform the
covenants herein contained at the time and in the manner herein provided. In the event of such termination the State may proceed with the work in any
manner deemed proper by the State. The cost to the State shall be deducted from any sum due the Contractor under this agreement, and the balance,
if any, shall be paid the Contractor upon demand.
Without the written consent of the State, this agreement is not assignable by Contractor either in whole or in part.
Time is of the essence in this agreement.
No alteration or variation of the terms of this contract shall be valid unless made in writing and signed by the parties hereto, and no oral understanding
or agreement not incorporated herein, shall be binding on any of the parties hereto.
The consideration to be paid Contractor, as provided herein, shall be in compensation for all of Contractor's expenses incurred in the performance
hereof, including travel and per diem, unless otherwise expressly so provided.
Federal Privacy Act disclosure: Disclosure of the Social Security Number is mandatory, and is collected by the Department under Section 8422.19 of
the California State Administrative Manual. It is used by the State Controller for tax reporting purposes.
Verification that the interpreter was present and submitted this claim may be signed by authorized county or state employees. The review and approval
for payment of such services will be done by CDSS staff.
DPA 302 (8/11)

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