Billing Form For Preschool Related Service Providers
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1Division of Financial Operations
Vendor Invoice #: _________
Bureau of Non-Public School Payables – Preschool Unit
Month: _________ Year: _________
Tel.: (718) 935-2161
_
Page _________ of ________
B
F
P
R
S
P
ILLING
ORM FOR
RESCHOOL
ELATED
ERVICE
ROVIDERS
Section 1: Student Information
Section 2: Provider Information
Student’s Name
: _____________________________________
Provider’s Name
: _____________________________________
(Last, First)
(Last, First)
NYC ID#: ___________________________________________________
Address: ___________________________________________________
Date of Birth: ________________
Home District: ________________
___________________________________________________
Related Service: _____________________________________________
Telephone #: _________________
SSN
: _________________
(Required)
IEP Recommendation:
Frequency: __________________
Duration: ____________________
Group Size: __________________
Language: ___________________
Location of Service: __________________________________________
Section 3: Agency Information
Student Assignment
Agency Name: _______________________________________________
(Check one):
Student was assigned to you/agency by CPSE after being selected
Agency Address: _____________________________________________
from the NYC Municipality List of Approved Preschool Related Service
_____________________________________________
Providers.
Agency Contact
: ______________________________________
Student was assigned to your agency as a result of being awarded the
(Last, First)
related service contract through the RFP process.
Federal Tax ID#: ______________________________________________
Contract #
: ________________________________________
Telephone #: _________________
Email: _______________________
(If applicable)
Comments: _________________________________________________
Section 4: Service Provision
Signature of
Signature of
RCV
parent/principal/designee verifying
RCV
parent/principal/designee verifying
Group
Start
End
that service was provided as
Group
Start
End
that service was provided as
Date
Size
Time
Time
indicated
Date
Size
Time
Time
indicated
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18
3
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21
6
22
7
23
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24
9
25
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30
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31
16
Section 5: Certification of Service Provision
Total # of Sessions: ___________
Rate: $_____________
I hereby certify that I provided related services on the dates and for the
durations indicated above. I understand that any material misrepresentation
Total Amount Due: $_______________________
of fact provided by me on this form may result in criminal action.
_______________________________________________________________
_______________________________________________________
Signature of Provider
Date
Signature of Agency/School Representative
Date
(Original required)
(If applicable; Original required)
Last Updated: 3-30-15
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