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picture1_Contractor Invoice Template Excel 40126 | Emsa Form 501b Contract Invoice


 171x       Filetype XLSX       File size 0.98 MB       Source: emsa.ca.gov


File: Contractor Invoice Template Excel 40126 | Emsa Form 501b Contract Invoice
sheet 1 instructions instructions for completing emsa s contractor reimbursement invoice work sheet name directions cell numbers invoice cover invoice information complete cells k3 k4 k5 k6 contractor information name ...

icon picture XLSX Filetype Excel XLSX | Posted on 14 Aug 2022 | 3 years ago
Partial file snippet.
Sheet 1: Instructions
Instructions for completing EMSA's Contractor Reimbursement Invoice
Work Sheet Name Directions Cell Numbers
Invoice (Cover) Invoice Information - Complete Cells: K3, K4, K5, K6

Contractor Information (Name and Address) - Complete Cells in Box: A8 - C12

Contract Number - Update: Line 14-15 for Contract Number

*Advance Payments (up to 25%) - Enter advance amounts, only if applicable: C27, E27, G27

Contractor Authorization - Print and Sign: A35 - K39



Invoice - Page 2 (Expenses) Contract Budget - Complete Cells: C9, C10, C14 - C27

Personnel Expenses - Do Not update (formula driven): E9 - E10

Operating Expenses - Complete Cells for actual expenses incurred by budget category: E14 - E27

*Prior Expenses - Move cumulative total of all current charges to prior expense columns as applicable and update cells: G9, G10, G14 - G27



Invoice - Page 3 (Personnel) Contract Personnel Costs - Complete Cells: B7, C7, D7, E7

Contract Personnel Costs - Complete row 8 through row 20 for additional staff, if applicable: through B20, C20, D20, E20

Contract Personnel Costs - Do not update (formula driven): G7 - G20

Contract Personnel Costs - Actual hours spent on this project - Complete Cells: H7 - H20

Contractor Personnel Benefit Rate - Actual rates that can be supported by payroll records for Retirement/OASDI/Medicare/Health & Welfare/Workers Compensation - Complete Cells: D25 - H25 through D38 - H38


Sheet 2: Invoice (Cover)

STATE OF CALIFORNIA
EMERGENCY MEDICAL SERVICES AUTHORITY
CONTRACTOR REIMBURSEMENT INVOICE
















DATE:
XXXXXXXX






CONTRACT NUMBER:
XXXXXXXX






INVOICE NUMBER:
XXXXXXXX






INVOICE PERIOD:
XXXXXXXX






INVOICE AMOUNT:
$-













































































Purpose of this invoice is to reimburse contractor for actual expenditures incurred while performing the activities agreed upon as contained in Contract Number #XXXXXXXX. Supporting documentation of requested reimbursement wil be provided upon request.
















Contract Contract Expenditures Remaining

Budget Categories
Budget Current
Prior
YTD Balance















Salary Expenses $-
$-
$-
$-
$-


Benefit Expenses $-
$-
$-
$-
$-


Operating Expenses $-
$-
$-
$-
$-









































Total $-
$-
$-
$-
$-


Less Advance (if applicable)





$-
$-


Total Reimbursement Request $-
$-
$-
$-
$-























































CEMSIS Data Review and Correction





































For EMSA Use Only



























Sheet 3: Invoice - Page 2 (Expenses)
Purpose of this page is to document contractor expenses.













Contract Expenditures Remaining
Budget Categories
Budget Current
Prior
YTD
Balance











Personnel Expenses
$- $-
$-
$-
$-











0 Salaries
$-


$-
$-
0 Benefits
$-


$-
$-











Operating Expenses Includes general Equipment Costs
$- $-
$-
$- $-












General Expenses




$-
$-

Printing




$-
$-

Communications




$-
$-

Postage




$-
$-

Insurance




$- $-
0 Travel In-State




$-
$-
0 Travel Out-of State




$-
$-
0 Training




$-
$-
0 Facilities Operations




$-
$-
0 Utilities




$-
$-
0 Departmental Indirect Costs




$-
$-
0 Information Technology




$-
$-

Sub Contracts





$-
$-

Other Items of Expense





$-
$-











Total Expenses
$-
$-
$-
$-
$-


The words contained in this file might help you see if this file matches what you are looking for:

...Sheet instructions for completing emsa s contractor reimbursement invoice work name directions cell numbers cover information complete cells k and address in box a c contract number update line advance payments up to enter amounts only if applicable e g authorization print sign page expenses budget personnel do not formula driven operating actual incurred by category prior move cumulative total of all current charges expense columns as costs b d row through additional staff hours spent on this project h benefit rate rates that can be supported payroll records retirementoasdimedicarehealth amp welfareworkers compensation state californiaemergency medical services authoritycontractor date xxxxxxxx period amount purpose is reimburse expenditures while performing the activities agreed upon contained supporting documentation requested wil provided request remaining categories ytd balance salary less cemsis data review correction use document salaries benefits includes general equipment prin...

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