Invoice and Compliance Certification Form Sample Clauses

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: