Invoicing Template

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Overview

Help Guide
Invoice
Invoice Report

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Sheet 1: Help Guide

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Sheet 2: Invoice

		Project Name		Template								Choose return option: 1)Email: [email protected] 2)Mail: RHC Pilot Program 30 Lanidex Plaza West PO Box 685 Parsippany NJ 07054-0685 3)Fax: 973-599-6518			FOR RHCD USE ONLY
		SPIN													Header Verification
		Vendor Name														RHCD Processed Date
		Vendor Invoice Number														Number of Records
		Invoice Date to RHCD (mm/dd/yy)														Number of Records Approved
		Total Invoice Amount			$0.00											RHCD Approved Total Amount
		FCL Amount Remaining Before This Invoice:			$0.00										1/11/81	Generated Date
		Funding Year													3/25/10	Template Build Date
		HCP Number			0			Amount committed on NCW and remaining after previously submitted invoices				Items Requested This Invoice			RHCPP Support Amount
		FRN
	DELETE	1. Invoice ID	2. NCW ID	3. Category	4. Sub Category	5. Item	6. Comments	7. Total # of Items / Months Remaining	8. Committed Total Cost per Item / Month (100%)	9. Total Eligible Cost (%)	10. Total Funds Remaining	11. Total # of Items / Months Requested	12. Total Actual Cost Per Item (100%) (as invoiced by vendor)	13. Total Eligible Cost ($) (total actual cost * %eligible)	14. RHC Funding % Requested (max 85%)	15. Support Amount to be paid by USAC (max 85%)		FRN	Code
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	Vendor Certification I certify that I am an authorized representative of the above-named vendor, that I have examined the information provided in the Rural Health Care Pilot Program Invoice, and to the best of my knowledge, information and belief, all costs contained in this invoice are true and correct and represent actual incurred costs for network build-out or related services received by each participating health care provider. Signature : _____________________________ Date : ________________________________ Phone# : _________________________ Print Name : _____________________________ Email : ________________________________ __________________________________________________________________________________________________________________________________________________________________________________ Project Coordinator Certification I certify that I have examined the information provided in the Rural Health Care Pilot Program Invoice, and to the best of my knowledge, information and belief, the participating health care providers have received the network build-out or related services itemized on this invoice. I certify under penalty of perjury that the 15 percent minimum funding contribution for each item on this invoice required by the Rural Health Care Pilot Program rules was funded by eligible sources as defined in the rules and has been provided to the vendor. Signature : _____________________________ Date : ________________________________ Phone# : _________________________ Print Name : _____________________________ Email : ________________________________

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Sheet 3: Invoice Report

"FRN"

FRN

Template Invoicing Report

10000

20000

20000

FRN:

Total Amount Committed:

$-

Funding Year:

Total Amount Invoiced:

$-

Service Provider:

Total Amount Remaining:

$-

SPIN:

Report Date:

1/11/1981

NCW ID

Category

Sub-Category

Component

Speed

Comments

Num of Items Committed

Cost Per Item

Num of Items Invoiced

Num of Items Remaining

$ Committed

$ Invoiced

$ Remaining

Funding Year

SPIN

FRN

NCW ID

SP Name

Category

Sub-Category

Item

Speed

Comments

# Committed

Committed Cost

# Invoiced

# Remaining

Total $ Committed

Total $ Invoiced

Total $ Remaining