Sample Invoice Template - Kentucky Department Of Education
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1EXAMPLE
INVOICE
Date: 6/28/2013
Invoice # SFSP HI#0001
To
Kentucky Health
Department
Kentucky Department of Education
100 Oak Street
Division of School and Community Nutrition
Somewhere, KY
2301 Capital Plaza Tower
40511
500 Mero Street
(502) 555-1212
Frankfort, KY 40601
Vendor #:
(502) 564-5625
VC123456789
Contact Name:
{Billing contact}
I n s p e c t i o n
I n s p e c t i o n
L i n e
C N I P S
S t a t u s
A m o u n t
S i t e N a m e
C o u n t y
C o m p l e t i o n
N o
I D #
( C o m p l e t e d /
D u e
D a t e
A t t e m p t e d )
Allen County
1
1005
Alco Apartments
6/10/2013
Completed
$200.00
Allen County
2
1011
Allen County Public Library
6/11/2013
Attempted
$150.00
1008
Allen County
3
Landmark Apartments
6/11/2013
Completed
$200.00
4
Completed: $200 per inspection
5
Attempted: $150 per inspection
6
7
Information taken from SFSP Health Inspection forms
8
9
10
11
12
13
14
15
16
17
T o t a l A m o u n t D u e
$550.00
As per the terms of the Contract, invoices shall include an itemized breakdown of
expenditures to include, but not limited to, identification of sites inspected and
copies of Health Inspection Reports.
Original Signature
Signed by Director of Health Dept./District
Please attach all completed SFSP Health Inspection forms; scanned forms and invoice
are acceptable.
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