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Provider Name Invoice #Invoice Date <br />Project Number (from SOW in Contract) <br />Program Name <br />JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Total <br />Fee for Service (IPRS)($0.00) <br />Fee for Service (Medicaid)($0.00) <br />Private Insurance/3rd Party Pay ($0.00) <br />Client Co-Pays ($0.00) <br />Contributions ($0.00) <br />Miscellaneous ($0.00) <br />Total Revenue ($0.00)($0.00)($0.00)($0.00)($0.00)($0.00)($0.00)($0.00)($0.00)($0.00)($0.00)($0.00)($0.00) <br />JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Total <br />Salaries/Wages/Benefits (Tab A)-$ <br />Travel/Staff Lodging/Meals (Tab B)-$ <br />Client Assistance/Activities (Tab C)-$ <br />Building Repair & Maintenance -$ <br />Communications -$ <br />Consulting Service/Fees -$ <br />Dues and Subscriptions -$ <br />Insurance - Motor Vehicle -$ <br />Insurance - Property and Liability -$ <br />Meeting/Conference Expense -$ <br />Office Equipment Rental (Phone/Computer)-$ <br />Office/Equipment Repair & Maintenance -$ <br />Office Expense -$ <br />Office Supplies & Materials -$ <br />Postage/Mailing Expense -$ <br />Rent - Building/Office Space -$ <br />Service Related Supplies -$ <br />Utilities -$ <br />Vehicle Expense -$ <br />Vehicle Rental -$ <br />Provider Specific Expenses (add below) <br />-$ <br />-$ <br />-$ <br />-$ <br />-$ <br />-$ <br />-$ <br />Sub-Total Expenses -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ <br />Administrative Overhead JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Total <br />Annual Admin Overhead (Tab D July ONLY)-$ <br />Total Expenses -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ <br />Invoice Amount Surplus (Deficit) -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ <br />Contract Max Budget Budget Remaining <br />-$ <br />Authorized Signature (only if mailed see note below) <br />Revenue ( Formatted to display as a negative number - don't <br />type in (-) negative sign ) <br />Expense ( Formatted to display as a positive number - type in (-) <br />before number for negative entry ) <br />-$ <br />BY SUBMISSION OF THIS INVOICE VIA EMAIL AND INCLUDING INVOICE NUMBER IN THE SUBJECT LINE, I ACKNOWLEDGE THAT ALL INFORMATION IS ACCURATE AND UNDERSTAND NO SIGNATURE IS REQUIRED <br />NON-UCR INVOICE TEMPLATE FOR CONTRACTS WITH ALLIANCE HEALTH REVISED 09-26-2023 <br />Contract Max for Program Service Month <br />Invoice Amount <br />Preparer's Phone or EmailType Name and Title Date <br />Docusign Envelope ID: B648A841-9C74-4DB1-87DA-A8851FFB1A84Docusign Envelope ID: 93CA2334-7774-43C5-B639-4A741A3162B9