Common use of Invoice and Compliance Certification Form Clause in Contracts

Invoice and Compliance Certification Form. This Invoice is a summary of all the costs that you are claiming at this time. If the costs encompass multiple deliverables, delineate the costs for each of the deliverables separately. Grantee: Street Address: City, State & Zip Code: Contact Email: Contact Phone (Include Area Code): Agreement Number: Invoice Number: Invoice Period (Dates): FEIN: Fax (Include Area Code): To: FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 DESCRIPTION: Deliverables Including Minimum Performance Standards Deliverable: (Specify the deliverable number, its description in the agreement, and the minimum performance standards met.) Costs Associated with the Deliverable: (List the costs to be reimbursed associated with this deliverable. Provide the Name of the Contractor, the Contractor Invoice #, and the period covered by the invoice. A copy of the invoice, proof of payment via the front and back of the cancelled check or the credit card payment, and a zero balance from the contractor should be attached.) Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider TOTAL AMOUNT OF INVOICES REQUESTED FOR REIMBURSEMENT: _ ______________ Grantee Certification: I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and conditions of the executed contract document on file. I understand that the office of the State Chief Financial Officer reserves the right to require additional documentation and/or to conduct post-audits of any agreements. Grantee Name printed: Title: Grantee Signature: Date: Exhibit D to Attachment 1 Xxx XxXxxxxx GOVERNOR Dane Eagle SECRETARY GRANT AGREEMENT FINAL CLOSEOUT FORM Recipient Name: DEO Agreement Number: Vendor ID (MyFloridaMarketplace): Initial Agreement Amount: FEIN: Amount of DEO Funds Deobligated (Forfeited): Contract End Date: Final Agreement Amount: Audit Report Date: Amount of Matching Funds Received:

Invoice and Compliance Certification Form. This Invoice is a summary of all the costs that you are claiming at this time. If the costs encompass multiple deliverablesdeliverabdlelsin, delineate eate the costs for each of the deliverables separately. Grantee: Street Address: City, State & Zip Code: Contact Email: Contact Phone (Include Area Code): :) Agreement Number: Invoice Number: Invoice Period (Dates): FEIN: Fax (Include Area Code): :) To: FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 DESCRIPTION: Deliverables Including Minimum Performance Standards Deliverable: (Specify the deliverable number, its description in descriptioinn the agreement, agreemen,t and the minimum performance standards met.) Costs Associated with the Deliverable: (List the costs to be reimbursed associated with this deliverable. Provide the Name of the Contractor, the Contractor Invoice #, and the period covered by the invoice. A copy of the invoice, proof of payment via the front viafrtohnet and back of the cancelled check or the credit card payment, and a zero balance from the contractor should be attachedshouldabtteached.) Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider TOTAL AMOUNT OF INVOICES REQUESTED FOR REIMBURSEMENT: _ ______________ Grantee Certification: I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and conditions of the executed contract document on file. I understand that the office of the State Chief Financial Officer reserves the right to require additional documentation and/or to conduct post-audits of any agreements. Grantee Name printed: Title: Grantee Signature: Date: Exhibit D to Attachment 1 Xxx XxXxxxxx GOVERNOR Dane Eagle SECRETARY EXECUTIVEDIRECTOR GRANT AGREEMENT FINAL CLOSEOUT FORM Recipient Name: DEO Agreement Number: Vendor ID (MyFloridaMarketplace): Initial Agreement Amount: FEIN: Amount of DEO Funds Deobligated (Forfeited): Contract End Date: Final Agreement Amount: Audit Report Date: Amount of Matching Funds Received:

Invoice and Compliance Certification Form. This Invoice is a summary of all the costs that you are claiming at this time. If the costs encompass multiple deliverables, delineate the costs for each of the deliverables separately. Grantee: Street Address: City, State & Zip Code: Contact Email: Contact Phone (Include Area Code): Agreement Number: Invoice Number: Invoice Period (Dates): NFA Number: FEIN: Fax (Include Area Code): To: FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 DESCRIPTION: Deliverables Including Minimum Performance Standards Deliverable: (Specify the deliverable number, its description in the agreement, and the minimum performance standards met.) Costs Associated with the Deliverable: (List the costs to be reimbursed associated with this deliverable. Provide the Name of the Contractor, the Contractor Invoice #, and the period covered by the invoice. A copy of the invoice, proof of payment via the front and back of the cancelled check or the credit card payment, and a zero balance from the contractor should be attached.) Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider TOTAL AMOUNT OF INVOICES REQUESTED FOR REIMBURSEMENT: _ _________________ Grantee Certification: I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and conditions of the executed contract document on file. I understand that the office of the State Chief Financial Officer reserves the right to require additional documentation and/or to conduct post-audits of any agreements. Grantee Name printed: Title: Grantee Signature: Date: Exhibit D Attachment 2 AUDIT REQUIREMENTS The administration of resources awarded by XXX to the recipient (herein otherwise referred to as “Grantee”) may be subject to audits and/or monitoring by DEO as described in this Attachment 1 Xxx XxXxxxxx GOVERNOR Dane Eagle SECRETARY GRANT AGREEMENT FINAL CLOSEOUT FORM Recipient Name: DEO Agreement Number: Vendor ID (MyFloridaMarketplace): Initial Agreement Amount: FEIN: Amount of DEO Funds Deobligated (Forfeited): Contract End Date: Final Agreement Amount: Audit Report Date: Amount of Matching Funds Received:2.

Invoice and Compliance Certification Form. This Invoice is a summary of all the costs that you are claiming at this time. If the costs encompass multiple deliverables, delineate the costs for each of the deliverables separately. Grantee: Agreement Number: Street Address: Invoice Number: City, State & Zip Code: Invoice Period (Dates): Contact Email: FEIN: Contact Phone (Include Area Code): Agreement Number: Invoice Number: Invoice Period (Dates): FEIN: Fax (Include Area Code): To: FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 DESCRIPTION: Deliverables Including Minimum Performance Standards Deliverable: (Specify the deliverable number, its description in the agreement, and the minimum performance standards met.) Costs Associated with the Deliverable: (List the costs to be reimbursed associated with this deliverable. Provide the Name of the Contractor, the Contractor Invoice #, and the period covered by the invoice. A copy of the invoice, proof of payment via the front and back of the cancelled check or the credit card payment, and a zero balance from the contractor should be attached.) Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider TOTAL AMOUNT OF INVOICES REQUESTED FOR REIMBURSEMENT: _ ______________ Grantee Certification: I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and conditions of the executed contract document on file. I understand that the office of the State Chief Financial Officer reserves the right to require additional documentation and/or to conduct post-audits of any agreements. Grantee Name printed: Title: Grantee Signature: Date: Exhibit D to Attachment 1 Xxx XxXxxxxx GOVERNOR Dane Eagle SECRETARY EXECUTIVE DIRECTOR GRANT AGREEMENT FINAL CLOSEOUT FORM Recipient Name: DEO Agreement Number: Vendor ID (MyFloridaMarketplace): Initial Agreement Amount: FEIN: Amount of DEO Funds Deobligated (Forfeited): Contract End Date: Final Agreement Amount: Audit Report Date: Amount of Matching Funds Received:

Invoice and Compliance Certification Form. This Invoice is a summary of all the costs that you are claiming at this time. If the costs encompass multiple deliverables, delineate the costs for each of the deliverables separately. Grantee: Street Address: City, State & Zip Code: Contact Email: Contact Phone ContactPhone (Include Area Code): Agreement Number: Invoice Number: Invoice Period (DatesPeriod(Dates): FEIN: Fax (Include Area Code): To: FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 DESCRIPTION: Deliverables Including Minimum Performance Standards Deliverable: (Specify the deliverable number, its description in the agreement, and the minimum performance standards met.) Costs Associated with the Deliverable: (List Deliverab:l(eList the costs to be reimbursed associated with this deliverable. Provide the Name of the Contractor, the Contractor Invoice #, and the period covered by the invoice. A copy of the invoice, proof of payment via the front and back of the cancelled check or the credit card payment, and a zero balance from the contractor should be attached.) Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider TOTAL AMOUNT OF INVOICES OFINVOICES REQUESTED FOR REIMBURSEMENT: _ _:________________ Grantee CertificationGranteeCertification: I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and tderms an conditions of the executed contract document on file. I understand that the office thaot tfhficee of the State Chief Financial Officer reserves the right to require additional documentation and/or to conduct post-audits -paousdtits of any agreements. Grantee Name GranteeName printed: Title: Grantee SignatureGranteeSignature: Date: Exhibit D to Attachment 1 Xxx XxXxxxxx GOVERNOR Dane Eagle SECRETARY EXECUTIVE DIRECTOR GRANT AGREEMENT FINAL CLOSEOUT FORM Recipient Name: DEO Agreement Number: Vendor ID (MyFloridaMarketplace): Initial Agreement Amount: FEIN: Amount of DEO Funds Deobligated (Forfeited): Contract End Date: Final Agreement Amount: Audit Report Date: Amount of Matching Funds Received:

Invoice and Compliance Certification Form. This Invoice is a summary of all the costs that you are claiming at this time. If the costs encompass multiple deliverables, delineate the costs for each of the deliverables separately. Grantee: Street Address: City, State & Zip Code: Contact Email: Contact Phone (Include Area Code): Agreement Number: Invoice Number: Invoice Period (Dates): FEIN: Fax (Include Area Code): To: FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 DESCRIPTION: Deliverables Including Minimum Performance Standards Deliverable: (Specify the deliverable number, its description in the agreement, and the minimum performance standards met.) Costs Associated with the Deliverable: (List the costs to be reimbursed associated with this deliverable. Provide the Name of the Contractor, the Contractor Invoice #, and the period covered by the invoice. A copy of the invoice, proof of payment via the front and back of the cancelled check or the credit card payment, and a zero balance from the contractor should be attached.) Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider TOTAL AMOUNT OF INVOICES REQUESTED FOR REIMBURSEMENT: _ ______________ Grantee Certification: I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and conditions of the executed contract document on file. I understand that the office of the State Chief Financial Officer reserves the right to require additional documentation and/or to conduct post-audits of any agreements. Grantee Name printed: Title: Grantee Signature: Date: Exhibit D to Attachment 1 Xxx XxXxxxxx GOVERNOR Dane Eagle SECRETARY EXECUTIVE DIRECTOR GRANT AGREEMENT FINAL CLOSEOUT FORM Recipient Name: DEO Agreement Number: Vendor ID (MyFloridaMarketplace): Initial Agreement Amount: FEIN: Amount of DEO Funds Deobligated (Forfeited): Contract End Date: Final Agreement Amount: Audit Report Date: Amount of Matching Funds Received:

Invoice and Compliance Certification Form. This Invoice is a summary of all the costs that you are claiming at this time. If the costs encompass multiple deliverables, delineate the costs for each of the deliverables separately. Grantee: Street Address: City, State & Zip Code: Contact Email: Contact Phone (Include Area Code): Agreement Number: Invoice Number: NFA Number: Invoice Period (Dates): FEIN: Fax (Include Area Code): To: FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 State Fiscal Year: 2022-2023 DESCRIPTION: Deliverables Including Minimum Performance Standards DeliverableDeliverable 1: (Specify the deliverable number, its description in the agreement, and the minimum performance standards met.) Costs Associated with the Deliverable: (List the costs to be reimbursed associated with this deliverable. Provide the Name of the Contractor, the Contractor Invoice #, and the period covered by the invoice. A copy of the itemized invoice, proof of payment via the front and back as identified in Section 2.D.1., Scope of the cancelled check or the credit card paymentWork, and a zero balance from the contractor should be attached.) Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider DeliverableDeliverable 2: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider DeliverableDeliverable 3: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider TOTAL AMOUNT OF INVOICES REQUESTED FOR REIMBURSEMENT: _ ______________ Grantee Certification: I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and conditions of the executed contract document on file. I understand that the office of the State Chief Financial Officer reserves the right to require additional documentation and/or to conduct post-audits of any agreements. Grantee Name printed: Title: Grantee Signature: Date: Exhibit D Agreement # S0189 Attachment II AUDIT REQUIREMENTS The administration of resources awarded by XXX to the recipient (herein otherwise referred to as “Grantee”) may be subject to audits and/or monitoring by DEO as described in this Attachment 1 Xxx XxXxxxxx GOVERNOR Dane Eagle SECRETARY GRANT AGREEMENT FINAL CLOSEOUT FORM Recipient Name: DEO Agreement Number: Vendor ID (MyFloridaMarketplace): Initial Agreement Amount: FEIN: Amount of DEO Funds Deobligated (Forfeited): Contract End Date: Final Agreement Amount: Audit Report Date: Amount of Matching Funds Received:2.

Invoice and Compliance Certification Form. This Invoice is a summary of all the costs that you are claiming at this time. If the costs encompass multiple deliverables, delineate the costs for each of the deliverables separately. Grantee: Street Address: City, State & Zip Code: Contact Email: Contact Phone (Include Area Code): Agreement Number: Invoice Number: Invoice Period (Dates): FEIN: Fax (Include Area Code): To: FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 DESCRIPTION: Deliverables Including Minimum Performance Standards Deliverable: (Specify the deliverable number, its description in the agreement, and the minimum performance standards met.) Costs Associated with the Deliverable: (List the costs to be reimbursed associated with this deliverable. Provide the Name of the Contractor, the Contractor Invoice #, and the period covered by the invoice. A copy of the invoice, proof of payment via the front and back of the cancelled check or the credit card payment, and a zero balance from the contractor should be attached.) Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider TOTAL AMOUNT OF INVOICES REQUESTED FOR REIMBURSEMENT: _ ______________ Grantee Certification: I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and conditions of the executed contract document on file. I understand that the office of the State Chief Financial Officer reserves the right to require additional documentation and/or to conduct post-audits of any agreements. Grantee Name printed: Title: Grantee Signature: Date: DocuSign Envelope ID: B88FF740-E824-4444-B1E4-E6B14AA0C485 Exhibit D to Attachment 1 Xxx XxXxxxxx GOVERNOR Dane Eagle SECRETARY GRANT AGREEMENT FINAL CLOSEOUT FORM Recipient Name: DEO Agreement Number: Vendor ID (MyFloridaMarketplace): Initial Agreement Amount: FEIN: Amount of DEO Funds Deobligated (Forfeited): Contract End Date: Final Agreement Amount: Audit Report Date: Amount of Matching Funds Received:

Invoice and Compliance Certification Form. This Invoice is a summary of all the costs that you are claiming at this time. If the costs encompass multiple deliverables, delineate the costs for each of the deliverables separately. Grantee: Street Address: City, State & Zip Code: Contact Email: Contact Phone (Include Area Code): Agreement Number: Invoice Number: Invoice Period (Dates): FEIN: Fax (Include Area Code): To: FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY 000 Xxxx Xxxxxxx Xxxxxx Xxxxxxxxxxx, XX 00000 DESCRIPTION: Deliverables Including Minimum Performance Standards Deliverable: (Specify the deliverable number, its description in the agreement, and the minimum performance standards met.) Costs Associated with the Deliverable: (List the costs to be reimbursed associated with this deliverable. Provide the Name of the Contractor, the Contractor Invoice #, and the period covered by the invoice. A copy of the invoice, proof of payment via the front and back of the cancelled check or the credit card payment, and a zero balance from the contractor should be attached.) Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider Deliverable: Costs Associated with the Deliverable: Invoice Invoice Invoice Date Contractor/ Amount Number Period Paid Provider TOTAL AMOUNT OF INVOICES REQUESTED FOR REIMBURSEMENT: _ _________________ Grantee Certification: I certify, by evidence of my signature below, the above information is true and correct; and accurately reflects the terms and conditions of the executed contract document on file. I understand that the office of the State Chief Financial Officer reserves the right to require additional documentation and/or to conduct post-audits of any agreements. Grantee Name printed: Title: Grantee Signature: Date: Exhibit D to Attachment 1 Xxx XxXxxxxx GOVERNOR Dane Eagle SECRETARY EXECUTIVE DIRECTOR GRANT AGREEMENT FINAL CLOSEOUT FORM Recipient Name: DEO Agreement Number: Vendor ID (MyFloridaMarketplace): Initial Agreement Amount: FEIN: Amount of DEO Funds Deobligated (Forfeited): Contract End Date: Final Agreement Amount: Audit Report Date: Amount of Matching Funds Received: