Flat Fee for Service
                                                                                                                                     FOR USE BEGINNING JULY 1, 2017                                                                                                        For First 5 LA Use Only
                                                                                                                                                                                                                                                                         Agreement #:
                                                                                                                                                                                                                                                                   Agreement Period:
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                                                      Submit Invoice To:                                                                                                                                                                                                     Project ID:
                                                          Invoice Period:                                                                                                                                                                                                    Vendor ID:
                                                           Agency Name:
                                                            Project Name:
                                  Description of Service or Task                                                                                                                                                                                                                                          Fee
                                                                                                                                                                                                                                                                                 TOTAL
                                                                                                                                                                                                                                                                    YTD Actual Totals
                                  I CERTIFY THAT THIS CLAIM IS IN ALL RESPECTS TRUE, CORRECT, AND SUPPORTABLE BY AVAILABLE DOCUMENTATION,                                                                                                                    Approved Budget Total*
                                  AND IN COMPLIANCE WITH ALL TERMS/CONDITIONS, LAW AND REGULATIONS GOVERNING ITS PAYMENT.                                                                                                                                     Total Budget Balance** $                                             -   
                                  Signature of Authorized Representative                                            Date
                                  Printed Name & Title 
                                  NOTES                                                                                                                                                                                                    For First 5 LA Use Only
                                                                                                                                                                                                                                                                 Budget Amendment:
                                                                                                                                                                                      Project Manager                                                               (Enter Effective Date)
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                                                                                                                                                                                      Supervisor                      Date                                              Final Payment:        ¨ Yes     ¨  No
                                                                                                                                                                                      Finance Dept.                   Date
                                                                                                                                                                                                                                                                                                                                         Updated 08/08/2022