Los Angeles Mission College
Memorandum
Date:
To: Business Office
From:
Subject: Request for Invoice
_____________________________________________________________________________________________________
Please issue an invoice to the following agency:
Agency name:
Attention of:
Address:
State, City, Zip:
Agency’s Contract #:
Agency’s Contract Period:
LACCD’s Fund #:
LACCD’s Fund Name:
Reporting Period:
Type of Invoice: Monthly__________ Quarterly_____________ Annually______________ Other____________
Grand total amount of Invoice:
Itemization:
Specify the information to be written on the invoice that tells the why, when, where and how the total invoice amount is
determined. If a very detailed description is required, write “TOTAL DUE PER ATTACHED SCHEDULE” and attach a
schedule based on the detail shown below. This will enable the Business Office to prepare the invoice correctly.
FOR EXAMPLE:
A) Itemize the salary expenditures:
Show personnel title, monthly salary, No. of items, the percentage of time assigned and the associated employee benefits.
B) Itemize the non-salary expenditures:
Show account titles, numbers of item purchased, unit cost and the extended cost.
C) Indicate applicable indirect Administrative cost and percentage.
Attach additional pages for all itemized lists for the above, as needed.
Please note: The sum of A, B and C above have to equal to the total invoice amount.
Certification: I certify that the information provided on this invoice request form is correct and based on actual expenditures for
the period being claimed; performed exclusively in connection with the contract number shown and that the payroll and other
supporting expenditure documents are on file.
________________________________________________
Program Director’s Name
____________________________________________________
Program Director’s Signature
Date