Sheet 1: Oct

	
	
	

		
Name of Agency: 
		
Provider Invoice Number: 
	
	

		
d/b/a: 
		
Date of Invoice:
	
	

		
Street Address: 
		
Billing Period (select month from list below)
	
	

		
City, State, Zip Code: 
		


	
	

		
Contact Person: 
		


	
	

		
Federal Tax ID : 
		


	
	

		


		


	
	

		
TO
		
FOR
	
	

		


		
DCS Contract Number: 
	
	

		
State of Indiana, Department of Child Services
		
State of Indiana Issued Purchase Order Number: 
	
	

		
402 W. Washington St. RM W386, MS 54
		


	
	

		
Indianapolis, In 46204
		


	
	

		


		


	
	

		
DEPARTMENT OF CHILD SERVICES
		
	

		
VOUCHER ATTACHMENT FOR THE  USE OF CAC FUNDS (SSBG/CJA)
		
	

		
Period of Service(Month/day/year to Month/day/year):
		


	
	

		
1.0  Personnel-Identify Staff Position and % of time
		


	
	

		
     1.  Salaries & Wages (Coordination, etc.)
		
 $-   
	
	

		
     2.  Fringe Benefits
		
 $-   
	
	

		
1.0 Total
		
 $-   
	
	

		
1.1 Personnel-Identify Staff Position and % of time
		


	
	

		
1.  Salaries & Wages (Costs associated with Forensic Interview)
		


	
	

		
2.  Fringe Benefits
		


	
	

		
 1.1 Total 
		
 $-   
	
	

		
2.0  Rent/Utilities
		


	
	

		
    1.  Rental Rate: (Rate X Months)
		


	
	

		
    2.  Utilities: Rate X Months)
		
 $-   
	
	

		
2.0 Total
		
 $-   
	
	

		
3.0 Telephone,  Postage, Supplies
		


	
	

		
    1.  Telephone
		


	
	

		
    2.  Postage
		
 $-   
	
	

		
    3.  Supplies
		
 $-   
	
	

		
3.0 Total
		
 $-   
	
	

		
4.0 Equipment, Purchase, Lease, Renovation Costs
		
 $-   
	
	

		
    1.  Equipment
		
 $-   
	
	

		
    2.  Lease of equipment
		


	
	

		
    3.  Renovation Costs(interview room/waiting room)
		
 $-   
	
	

		
4.0 Total
		
 $-   
	
	

		
5.0  Travel
		


	
	

		
    1.  Airfare
		


	
	

		
    2.  Mileage ($ .38/mile)
		
 $-   
	
	

		
    3.  Registration-In-state and Out of State
		
 $-   
	
	

		
    4.  Lodging
		
 $-   
	
	

		
    5.  Ground Transportation
		
 $-   
	
	

		
    6.  Daily Subsistance (must be based on the State's allowance-$26/Day/In-state and $32/Day Out-of-State)
		
 $-   
	
	

		
5.0 Total 
		
 $-   
	
	

		
6.0  Training (Local Training)
		


	
	

		
7.0  Translation Services
		


	
	

		
8.0  Court Costs
		


	
	

		


		


	
	

		
I. Total for all lines of Invoice
		
 $-   
	
	

		
Pursuant to the provisions and penalties of Indiana Code 5-1-11-10-1, I hereby certify that the foregoing invoice is just and correct, that the amount claimed is legally due, after allowing all just credits, and that no part of the same service has been paid.  I HEREBY SWEAR AND AFFIRM UNDER THE PENALTIES OF PERJURY THE ATTACHED INVOICE CONTAINS THE ACTUAL SERVICE COSTS PROVIDED FOR THE SERVICES ON SUCH BILL.  THE DATES, DAYS, HOURS AND UNITS OF TIME AND COSTS FOR THE SERVICES ARE TRUE AND ACCURATE.  I UNDERSTAND THAT IN SUBMITTING THIS THAT I AM UNDER OATH STATING AND AFFIRMING THAT THE SERVICES LISTED WERE PROVIDED AND FULLY UNDERSTAND THAT THESE SERVICES MAY BE INDEPENDENTLY AUDIDTED AND THAT ANY DISCREPANCY MAY BE REFERRED TO A LOCAL PROSECUTOR FOR CRIMINAL PROSECUTION.
		
	

		


		


	
	

		
Authorized Signer's Printed Name: 
		


	
	

		
Authorized Signer's Signature:
		


	
	

		


		


	
	

		
DCS APPROVAL TO PAY INVOICE
		


	
	

		


		


	
	

		
______________________________________________________________
		


	
	

		
Programs Signature
		
Date
	
	

		


		


	
	

		
_______________________________________________________________
		


	
	

		
Buyers Signature
		
Date
	



Sheet 2: Nov

	
	
	

		
Name of Agency: 
		
Provider Invoice Number: 
	
	

		
d/b/a: 
		
Date of Invoice: 
	
	

		
Street Address: 
		
Billing Period (select month from list below)
	
	

		
City, State, Zip Code: 
		


	
	

		
Contact Person: 
		


	
	

		
Federal Tax ID :  
		


	
	

		


		


	
	

		
TO
		
FOR
	
	

		


		
DCS Contract Number: 
	
	

		
State of Indiana, Department of Child Services
		
State of Indiana Issued Purchase Order Number:
	
	

		
402 W. Washington St. RM W386, MS 54
		


	
	

		
Indianapolis, In 46204
		


	
	

		


		


	
	

		
DEPARTMENT OF CHILD SERVICES
		
	

		
VOUCHER ATTACHMENT FOR THE  USE OF CAC FUNDS (SSBG/CJA)
		
	

		
Period of Service(Month/day/year to Month/day/year):
		
0
	
	

		
1.0  Personnel-Identify Staff Position and % of time
		


	
	

		
     1.  Salaries & Wages (Coordination, etc.)
		
 $-   
	
	

		
     2.  Fringe Benefits
		
 $-   
	
	

		
1.0 Total
		
 $-   
	
	

		
1.1 Personnel-Identify Staff Position and % of time
		


	
	

		
1.  Salaries & Wages (Costs associated with Forensic Interview)
		


	
	

		
2.  Fringe Benefits
		


	
	

		
 1.1 Total 
		
 $-   
	
	

		
2.0  Rent/Utilities
		


	
	

		
    1.  Rental Rate: (Rate X Months)
		


	
	

		
    2.  Utilities: Rate X Months)
		
 $-   
	
	

		
2.0 Total
		
 $-   
	
	

		
3.0 Telephone,  Postage, Supplies
		


	
	

		
    1.  Telephone
		


	
	

		
    2.  Postage
		
 $-   
	
	

		
    3.  Supplies
		
 $-   
	
	

		
3.0 Total
		
 $-   
	
	

		
4.0 Equipment, Purchase, Lease, Renovation Costs
		
 $-   
	
	

		
    1.  Equipment
		
 $-   
	
	

		
    2.  Lease of equipment
		


	
	

		
    3.  Renovation Costs(interview room/waiting room)
		
 $-   
	
	

		
4.0 Total
		
 $-   
	
	

		
5.0  Travel
		


	
	

		
    1.  Airfare
		


	
	

		
    2.  Mileage ($ .38/mile)
		
 $-   
	
	

		
    3.  Registration-In-state and Out of State
		
 $-   
	
	

		
    4.  Lodging
		
 $-   
	
	

		
    5.  Ground Transportation
		
 $-   
	
	

		
    6.  Daily Subsistance (must be based on the State's allowance-$26/Day/In-state and $32/Day Out-of-State)
		
 $-   
	
	

		
5.0 Total 
		
 $-   
	
	

		
6.0  Training (Local Training)
		


	
	

		
7.0  Translation Services
		


	
	

		
8.0  Court Costs
		


	
	

		


		


	
	

		
I. Total for all lines of Invoice
		
 $-   
	
	

		
Pursuant to the provisions and penalties of Indiana Code 5-1-11-10-1, I hereby certify that the foregoing invoice is just and correct, that the amount claimed is legally due, after allowing all just credits, and that no part of the same service has been paid.  I HEREBY SWEAR AND AFFIRM UNDER THE PENALTIES OF PERJURY THE ATTACHED INVOICE CONTAINS THE ACTUAL SERVICE COSTS PROVIDED FOR THE SERVICES ON SUCH BILL.  THE DATES, DAYS, HOURS AND UNITS OF TIME AND COSTS FOR THE SERVICES ARE TRUE AND ACCURATE.  I UNDERSTAND THAT IN SUBMITTING THIS THAT I AM UNDER OATH STATING AND AFFIRMING THAT THE SERVICES LISTED WERE PROVIDED AND FULLY UNDERSTAND THAT THESE SERVICES MAY BE INDEPENDENTLY AUDIDTED AND THAT ANY DISCREPANCY MAY BE REFERRED TO A LOCAL PROSECUTOR FOR CRIMINAL PROSECUTION.
		
	

		


		


	
	

		
Authorized Signer's Printed Name: 
		


	
	

		
Authorized Signer's Signature:
		


	
	

		


		


	
	

		
DCS APPROVAL TO PAY INVOICE
		


	
	

		


		


	
	

		
______________________________________________________________
		


	
	

		
Programs Signature
		
Date
	
	

		


		


	
	

		
_______________________________________________________________
		


	
	

		
Buyers Signature
		
Date
	



Sheet 3: Dec

	
	
	

		
Name of Agency: 
		
Provider Invoice Number: 
	
	

		
d/b/a: 
		
Date of Invoice:
	
	

		
Street Address: 
		
Billing Period (select month from list below)
	
	

		
City, State, Zip Code: 
		


	
	

		
Contact Person: 
		


	
	

		
Federal Tax ID :  
		


	
	

		


		


	
	

		
TO
		
FOR
	
	

		


		
DCS Contract Number: 
	
	

		
State of Indiana, Department of Child Services
		
State of Indiana Issued Purchase Order Number: 
	
	

		
402 W. Washington St. RM W386, MS 54
		


	
	

		
Indianapolis, In 46204
		


	
	

		


		


	
	

		
DEPARTMENT OF CHILD SERVICES
		
	

		
VOUCHER ATTACHMENT FOR THE  USE OF CAC FUNDS (SSBG/CJA)
		
	

		
Period of Service(Month/day/year to Month/day/year):
		
0
	
	

		
1.0  Personnel-Identify Staff Position and % of time
		


	
	

		
     1.  Salaries & Wages (Coordination, etc.)
		
 $-   
	
	

		
     2.  Fringe Benefits
		
 $-   
	
	

		
1.0 Total
		
 $-   
	
	

		
1.1 Personnel-Identify Staff Position and % of time
		


	
	

		
1.  Salaries & Wages (Costs associated with Forensic Interview)
		


	
	

		
2.  Fringe Benefits
		


	
	

		
 1.1 Total 
		
 $-   
	
	

		
2.0  Rent/Utilities
		


	
	

		
    1.  Rental Rate: (Rate X Months)
		


	
	

		
    2.  Utilities: Rate X Months)
		
 $-   
	
	

		
2.0 Total
		
 $-   
	
	

		
3.0 Telephone,  Postage, Supplies
		


	
	

		
    1.  Telephone
		


	
	

		
    2.  Postage
		
 $-   
	
	

		
    3.  Supplies
		
 $-   
	
	

		
3.0 Total
		
 $-   
	
	

		
4.0 Equipment, Purchase, Lease, Renovation Costs
		
 $-   
	
	

		
    1.  Equipment
		
 $-   
	
	

		
    2.  Lease of equipment
		


	
	

		
    3.  Renovation Costs(interview room/waiting room)
		
 $-   
	
	

		
4.0 Total
		
 $-   
	
	

		
5.0  Travel
		


	
	

		
    1.  Airfare
		


	
	

		
    2.  Mileage ($ .38/mile)
		
 $-   
	
	

		
    3.  Registration-In-state and Out of State
		
 $-   
	
	

		
    4.  Lodging
		
 $-   
	
	

		
    5.  Ground Transportation
		
 $-   
	
	

		
    6.  Daily Subsistance (must be based on the State's allowance-$26/Day/In-state and $32/Day Out-of-State)
		
 $-   
	
	

		
5.0 Total 
		
 $-   
	
	

		
6.0  Training (Local Training)
		


	
	

		
7.0  Translation Services
		


	
	

		
8.0  Court Costs
		


	
	

		


		


	
	

		
I. Total for all lines of Invoice
		
 $-   
	
	

		
Pursuant to the provisions and penalties of Indiana Code 5-1-11-10-1, I hereby certify that the foregoing invoice is just and correct, that the amount claimed is legally due, after allowing all just credits, and that no part of the same service has been paid.  I HEREBY SWEAR AND AFFIRM UNDER THE PENALTIES OF PERJURY THE ATTACHED INVOICE CONTAINS THE ACTUAL SERVICE COSTS PROVIDED FOR THE SERVICES ON SUCH BILL.  THE DATES, DAYS, HOURS AND UNITS OF TIME AND COSTS FOR THE SERVICES ARE TRUE AND ACCURATE.  I UNDERSTAND THAT IN SUBMITTING THIS THAT I AM UNDER OATH STATING AND AFFIRMING THAT THE SERVICES LISTED WERE PROVIDED AND FULLY UNDERSTAND THAT THESE SERVICES MAY BE INDEPENDENTLY AUDIDTED AND THAT ANY DISCREPANCY MAY BE REFERRED TO A LOCAL PROSECUTOR FOR CRIMINAL PROSECUTION.
		
	

		


		


	
	

		
Authorized Signer's Printed Name: 
		


	
	

		
Authorized Signer's Signature:
		


	
	

		


		


	
	

		
DCS APPROVAL TO PAY INVOICE
		


	
	

		


		


	
	

		
______________________________________________________________
		


	
	

		
Programs Signature
		
Date
	
	

		


		


	
	

		
_______________________________________________________________
		


	
	

		
Buyers Signature
		
Date