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INVOICE #
PART I

CONTRACTOR REPORTING PERIOD

ADDRESS

PROGRAM ACTIVITY CONTRACT NUMBER

PART II Accrued Expenditures by Cost Categories

Expenditures Budget Budget
Month Cumulative Approved Unspent $ Unspent %
01. ADMINISTRATION
01. Salaries -
02. Fringe Benefits -
03. Staff Travel & Conference Expenses -
04. Operating Expenses, Materials & Supplies* -
05. Non-Expendable Property* -
06. Rental of Space -
07. Operating Expenses -
08. Indirect Costs -
09. Other Costs -
-
TOTAL 01. ADMINISTRATIVE COSTS - - $ - -

02. PROGRAM COSTS

01. Salaries -
02. Fringe Benefits -
03. Staff Travel & Conference Expenses -
04. Operating Expenses, Materials & Supplies* -
05. Non-Expendable Property* -
06. Rental Space -
07. Operating Expenses -
09. Other Costs -
10. Work Experience -
11. Tuition & Fees -
12. Transportation -
13. Health Care -
14. Uniforms -
-
TOTAL 02. PROGRAM COSTS $ - - $ - -

GRAND TOTAL - - $ - -

PART III I hereby certify that this report conforms to our organization's accounting
records and complies with the terms and conditions of the agreement.

Signature Date

477354917.xls
 Print Name and Title Phone

* Attach invoice copy supporting expenditures

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477354917.xls