Invoice Template - California Department Of Health Care Services

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INVOICE
[Organization Name]
DATE
INVOICE #
[Street Address]
Invoice Period:
[City, ST ZIP Code]
[Phone]
Agreement Number:
BILL TO:
California Department of Health Care Services
Medi-Cal Dental Services Division
1501 Capitol Ave, MS 4900
Sacramento, CA 95814
916-464-3888
Time Period
Description
Amount
Totals
Personnel: (List each person in which salaries are invoiced)
Position Title
$XXX
Position Title
$XXX
Position Title
$XXX
Fringe Benefits (X%)
$XXX
Total Personnel
$0.00
Operating Expenses:(List each expense separately)
Item 1
$XXX
item 2
$XXX
Item 3
$XXX
Etc…
$XXX
Total Ops. Expenses
$0.00
Equipment: (Each equipment purchase separately)
Equipment expense Item 1
$XXX
Equipment expense Item 2
$XXX
Equipment expense Item 3
$XXX
Etc…
$XXX
Total Equipment
$0.00
Travel: (Each trip expense)
Travel Expense 1
$XXX
Travel Expense 2
$XXX
Travel Expense 3
$XXX
Etc…
$XXX
Total Travel
$0.00
Subcontractor 1: (Each subcontractor line item separately)
Subcontractor 1 Personnel
$XXX
Subcontractor 1 Operating Expenses
$XXX
Subcontractor 1 Travel
$XXX
Subcontractor 1 Equipment
$XXX
Subcontractor 1 Indirect Costs
$XXX
Total Subcontractor 1
$0.00
Subcontractor 2: (Each subcontractor line item separately)
Subcontractor 1 Personnel
$XXX
Subcontractor 1 Operating Expenses
$XXX
Subcontractor 1 Travel
$XXX
Subcontractor 1 Equipment
$XXX
Subcontractor 1 Indirect Costs
$XXX
* Repeat for Each Subcontractor
Total Subcontractor 2
$0.00
Other Misc. Costs: (each line item)
XXX
$XXX
XXX
$XXX
Total Misc. Costs
$0.00
Indirect Costs @ XXX%
XXX
$XXX
Total Indirect Costs
$0.00
Total Due
$0.00
Make all warrants payable to:
[Organization Name]
[Street Address]
[City, ST ZIP Code]
[Phone]

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