INVOICE
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2
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(mailing street address)
(mailing city, state, ZIP code)
(WVDE USE: Vendor Number – DO NOT USE SSN)
DATE
Document ID #
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Customer:
(first & last name)
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(invoice date)
(WVDE USE: DOC#)
West Virginia Department of Education
Building 6, Room 204
1900 Kanawha Boulevard East
Charleston, WV 25305
Payment is requested in the amount of $
for
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(invoice amount*)
the following date/s
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(exact dates only)
Description of service(s):
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(description)
*If no fee is requested, enter the amount $0.00 to process a zero dollar invoice and explain above why no fee is requested (i.e. this is for travel reimbursement only).
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(signature of vendor)
WVDE USE ONLY
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I certify the above consultant has completed his/her commitment to the West Virginia Department of Education and
that payment is hereby authorized.
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Date
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(signature of person certifying invoice)
Originating Office Name
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16
18
15
$
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$
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3234
$
Grand Total
$
Service agreement (fee) to be paid?
3210
(yes)
(no)
(yes)
(no)
(yes)
(no)
Travel expenses to be reimbursed?
3212
Stipend fee to be paid?
20
(rev. 9/2015)
1If individual performing services, enter first and last name. If agency performing services, enter agency's name.
2Insert the address where payment is to be mailed. This address shou ld be the same as the address in the wvOASI S sy stem. If not, a W-9 form will need to be completed.
3Insert the address where payment is to be mailed. This address shou ld be the same as the address in the wvOASI S sy stem. If not, a W-9 form will need to be completed..
4(MUST BE C OMPLETED BY OFF ICE P ERSONN EL IN ITI ATING THI S FORM) En ter the ind ividual's or agency 's Vendor #. DO NOT ENTER SSN.
5Enter date of invoice.
6(MUST BE C OMPLETED BY OFF ICE P ERSONN EL IN ITI ATING THI S FORM) E nter the prior approved Document ID Number - either from a service agreement, stipend contract or conference worksheet.
7Total amount for this invo ice.
Exa mple: $30 0. You will enter the total amount o n this line. Then, enter this total amount under one object code, or divide among the object codes located under the WVDE U SE ONLY b ox at the bo ttom.
8Exa mple: July 6-7, 2015 & Ju ly 9, 2015 -OR- J uly 13-15, 2015 . Day s shown shou ld represent only the day s services were rendered. ****IMPOR TANT** ** The dates entered here must be in the timeframe of the dates entered on the travel reimbursement form, if any .
9Service agreement description sh ould state: __ _____ services rendered.
Exa mple: Trained individuals on M icrosoft Office. $100 per day for 3 day s.
10USE BLU E IN K ON LY… Sig nature of the ind ividua l lis ted above; or, if agency , the signature of an agency representative.
11MUST BE COMPLETED BY OFFICE PERSONN EL INITIATING THIS FO RM .
12 Signature date of person certify ing invoice.
13 Person who initiated the agreement within the office.
14 (Must be a nswered wit h yes or no.) Mar k an (X) in the y es or no box.
15 Enter the amount of this inv oice that is charged for services, if any .
16 (Must be a nswered wit h yes or no.) Mar k an (X) in the y es or no box.
17 If travel is to be reimbursed, enter the amount from the travel expense account settlement form here. Be sure to submit the completed travel form and all required documentation with this invo ice.
18 (Must be a nswered wit h yes or no.) Mar k an (X) in the y es or no box.
19 Enter the amount of this inv oice charged for stipend, if any . This line item would be used for any amount paid for attending a training on ly .
20 Total of all 3 O bject Codes. Total shou ld equal the invoice amount.