Sheet 1: 3465

	
	
	
	
	
	
	
	
	
	
	
	
	

		
State of Kansas
		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
Department for Children and Families
		


		


		


		
Invoice and Timesheet: Purchase of Service
		


		


		
11/2011
		
	

		
Accounting & Administrative Operations
		


		


		


		


		


		
ADM-3465
		
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		
(Please print legibly)
		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
SMART ID
		
Address #
		
Location #
		
Region/County
		
Voucher #
		
Date
		
IMPREST:   
		
Yes
		


	
	

		


		


		


		


		


		


		


		


		


		
No
		


	
	

		
Vendor:
		


		
Caseworker Name:
		


		
Warrant#:              
		


		
	

		
Address:
		


		
Service Dates
		
Date:                     
		


		
	

		
City/State/Zip:
		


		
From:
		


		
To:
		


		
Prepared by
		
	

		
Vendor Invoice or Account #:
		


		
Program Type:
		


		


		
	

		


		
	

		
Client Name
		
KAECSES/KanPay #
		
Client Number
		


		


		
INF45
		


		
	

		
(As in Kaesces; last name, first name)
		
(8 Digits)
		
(10 Digits)
		
Speedchart
		
Account #
		
Code
		
Amount
		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		
Sub-Total From Page 2:
		
$0.00 
		
	

		


		


		


		
Grand Total:
		
$0.00 
		
	

		
Description of payment:  (For Imprest payment, describe emergency circumstance requiring immediate payment.  For Vendor payment, describe service provided)
		
	

		


		
	

		
Signatures:   I authorize the above services.   
		
Vendor Certification:
		
	

		
DCF Worker:  
		


		
Date:  
		


		
I certify these services/materials have been provided and that this invoice is correct and remains unpaid.
		
	

		
DCF Supervisor:
		


		
Date:  
		


		
 Vendor:  ______________________________  Date: _________________
		


		
Date: 
		


		
	

		
Imprests:
		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
Signature of client or worker that received warrant:
		


		
Date: 
		


		
	

		
Otherwise, status of warrant:
		


		
	

		
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		

 
		
		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	



Sheet 2: Page 2

	
	
	
	
	
	
	
	
	
	
	
	
	
	
	

		
Page 2 
		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
Payment Details Continued
		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
Client Name
		
KAECSES/ KANPAY#
		
Client Number
		
Speedchart
		
SMART  
		
INF45
		
Amount
		
	

		
(As in Kaesces; last name, first name)
		
(8 digits)
		
(10 Digits)
		


		
Account #
		
Code
		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		


		


		


		
	

		


		


		


		


		
Subtotal Page 2
		
$0.00