Invoicing Template

---

Overview

Help Guide
Invoice
Invoice Report

---

Sheet 1: Help Guide

---

Sheet 2: Invoice

		Project Name		Template								Choose return option: 1)Email: RHCPilot@usac.org 2)Mail: RHC Pilot Program 30 Lanidex Plaza West PO Box 685 Parsippany NJ 07054-0685 3)Fax: 973-599-6518			FOR RHCD USE ONLY
		SPIN													Header Verification
		Vendor Name														RHCD Processed Date
		Vendor Invoice Number														Number of Records
		Invoice Date to RHCD (mm/dd/yy)														Number of Records Approved
		Total Invoice Amount			$0.00											RHCD Approved Total Amount
		FCL Amount Remaining Before This Invoice:			$0.00										1/11/81	Generated Date
		Funding Year													3/25/10	Template Build Date
		HCP Number			0			Amount committed on NCW and remaining after previously submitted invoices				Items Requested This Invoice			RHCPP Support Amount
		FRN
	DELETE	1. Invoice ID	2. NCW ID	3. Category	4. Sub Category	5. Item	6. Comments	7. Total # of Items / Months Remaining	8. Committed Total Cost per Item / Month (100%)	9. Total Eligible Cost (%)	10. Total Funds Remaining	11. Total # of Items / Months Requested	12. Total Actual Cost Per Item (100%) (as invoiced by vendor)	13. Total Eligible Cost ($) (total actual cost * %eligible)	14. RHC Funding % Requested (max 85%)	15. Support Amount to be paid by USAC (max 85%)		FRN	Code
		1																	____
		2																	____
		3																	____
		4																	____
		5																	____
		6																	____
		7																	____
		8																	____
		9																	____
		10																	____
		11																	____
		12																	____
		13																	____
		14																	____
		15																	____
		16																	____
		17																	____
		18																	____
		19																	____
		20																	____
		21																	____
		22																	____
		23																	____
		24																	____
		25																	____
		26																	____
		27																	____
		28																	____
		29																	____
		30																	____
		31																	____
		32																	____
		33																	____
		34																	____
		35																	____
		36																	____
		37																	____
		38																	____
		39																	____
		40																	____
		41																	____
		42																	____
		43																	____
		44																	____
		45																	____
		46																	____
		47																	____
		48																	____
		49																	____
		50																	____
		51																	____
		52																	____
		53																	____
		54																	____
		55																	____
		56																	____
		57																	____
		58																	____
		59																	____
		60																	____
		61																	____
		62																	____
		63																	____
		64																	____
		65																	____
		66																	____
		67																	____
		68																	____
		69																	____
		70																	____
		71																	____
		72																	____
		73																	____
		74																	____
		75																	____
		76																	____
		77																	____
		78																	____
		79																	____
		80																	____
		81																	____
		82																	____
		83																	____
		84																	____
		85																	____
		86																	____
		87																	____
		88																	____
		89																	____
		90																	____
		91																	____
		92																	____
		93																	____
		94																	____
		95																	____
		96																	____
		97																	____
		98																	____
		99																	____
		100																	____
		101																	____
		102																	____
		103																	____
		104																	____
		105																	____
		106																	____
		107																	____
		108																	____
		109																	____
		110																	____
		111																	____
		112																	____
		113																	____
		114																	____
		115																	____
		116																	____
		117																	____
		118																	____
		119																	____
		120																	____
		121																	____
		122																	____
		123																	____
		124																	____
		125																	____
		126																	____
		127																	____
		128																	____
		129																	____
		130																	____
		131																	____
		132																	____
		133																	____
		134																	____
		135																	____
		136																	____
		137																	____
		138																	____
		139																	____
		140																	____
		141																	____
		142																	____
		143																	____
		144																	____
		145																	____
		146																	____
		147																	____
		148																	____
		149																	____
		150																	____
		151																	____
		152																	____
		153																	____
		154																	____
		155																	____
		156																	____
		157																	____
		158																	____
		159																	____
		160																	____
		161																	____
		162																	____
		163																	____
		164																	____
		165																	____
		166																	____
		167																	____
		168																	____
		169																	____
		170																	____
		171																	____
		172																	____
		173																	____
		174																	____
		175																	____
		176																	____
		177																	____
		178																	____
		179																	____
		180																	____
		181																	____
		182																	____
		183																	____
		184																	____
		185																	____
		186																	____
		187																	____
		188																	____
		189																	____
		190																	____
		191																	____
		192																	____
		193																	____
		194																	____
		195																	____
		196																	____
		197																	____
		198																	____
		199																	____
		200																	____
		201																	____
		202																	____
		203																	____
		204																	____
		205																	____
		206																	____
		207																	____
		208																	____
		209																	____
		210																	____
		211																	____
		212																	____
		213																	____
		214																	____
		215																	____
		216																	____
		217																	____
		218																	____
		219																	____
		220																	____
		221																	____
		222																	____
		223																	____
		224																	____
		225																	____
		226																	____
		227																	____
		228																	____
		229																	____
		230																	____
		231																	____
		232																	____
		233																	____
		234																	____
		235																	____
		236																	____
		237																	____
		238																	____
		239																	____
		240																	____
		241																	____
		242																	____
		243																	____
		244																	____
		245																	____
		246																	____
		247																	____
		248																	____
		249																	____
		250																	____
		251																	____
		252																	____
		253																	____
		254																	____
		255																	____
		256																	____
		257																	____
		258																	____
		259																	____
		260																	____
		261																	____
		262																	____
		263																	____
		264																	____
		265																	____
		266																	____
		267																	____
		268																	____
		269																	____
		270																	____
		271																	____
		272																	____
		273																	____
		274																	____
		275																	____
		276																	____
		277																	____
		278																	____
		279																	____
		280																	____
		281																	____
		282																	____
		283																	____
		284																	____
		285																	____
		286																	____
		287																	____
		288																	____
		289																	____
		290																	____
		291																	____
		292																	____
		293																	____
		294																	____
		295																	____
		296																	____
		297																	____
		298																	____
		299																	____
		300																	____
		301																	____
		302																	____
		303																	____
		304																	____
		305																	____
		306																	____
		307																	____
		308																	____
		309																	____
		310																	____
		311																	____
		312																	____
		313																	____
		314																	____
		315																	____
		316																	____
		317																	____
		318																	____
		319																	____
		320																	____
		321																	____
		322																	____
		323																	____
		324																	____
		325																	____
		326																	____
		327																	____
		328																	____
		329																	____
		330																	____
		331																	____
		332																	____
		333																	____
		334																	____
		335																	____
		336																	____
		337																	____
		338																	____
		339																	____
		340																	____
		341																	____
		342																	____
		343																	____
		344																	____
		345																	____
		346																	____
		347																	____
		348																	____
		349																	____
		350																	____
		351																	____
		352																	____
		353																	____
		354																	____
		355																	____
		356																	____
		357																	____
		358																	____
		359																	____
		360																	____
		361																	____
		362																	____
		363																	____
		364																	____
		365																	____
		366																	____
		367																	____
		368																	____
		369																	____
		370																	____
		371																	____
		372																	____
		373																	____
		374																	____
		375																	____
		376																	____
		377																	____
		378																	____
		379																	____
		380																	____
		381																	____
		382																	____
		383																	____
		384																	____
		385																	____
		386																	____
		387																	____
		388																	____
		389																	____
		390																	____
		391																	____
		392																	____
		393																	____
		394																	____
		395																	____
		396																	____
		397																	____
		398																	____
		399																	____
		400																	____
		401																	____
		402																	____
		403																	____
		404																	____
		405																	____
		406																	____
		407																	____
		408																	____
		409																	____
		410																	____
		411																	____
		412																	____
		413																	____
		414																	____
		415																	____
		416																	____
		417																	____
		418																	____
		419																	____
		420																	____
		421																	____
		422																	____
		423																	____
		424																	____
		425																	____
		426																	____
		427																	____
		428																	____
		429																	____
		430																	____
		431																	____
		432																	____
		433																	____
		434																	____
		435																	____
		436																	____
		437																	____
		438																	____
		439																	____
		440																	____
		441																	____
		442																	____
		443																	____
		444																	____
		445																	____
		446																	____
		447																	____
		448																	____
		449																	____
		450																	____
		451																	____
		452																	____
		453																	____
		454																	____
		455																	____
		456																	____
		457																	____
		458																	____
		459																	____
		460																	____
		461																	____
		462																	____
		463																	____
		464																	____
		465																	____
		466																	____
		467																	____
		468																	____
		469																	____
		470																	____
		471																	____
		472																	____
		473																	____
		474																	____
		475																	____
		476																	____
		477																	____
		478																	____
		479																	____
		480																	____
		481																	____
		482																	____
		483																	____
		484																	____
		485																	____
		486																	____
		487																	____
		488																	____
		489																	____
		490																	____
		491																	____
		492																	____
		493																	____
		494																	____
		495																	____
		496																	____
		497																	____
		498																	____
		499																	____
		500																	____
		501																	____
		502																	____
		503																	____
		504																	____
		505																	____
		506																	____
		507																	____
		508																	____
		509																	____
		510																	____
		511																	____
		512																	____
		513																	____
		514																	____
		515																	____
		516																	____
		517																	____
		518																	____
		519																	____
		520																	____
		521																	____
		522																	____
		523																	____
		524																	____
		525																	____
		526																	____
		527																	____
		528																	____
		529																	____
		530																	____
		531																	____
		532																	____
		533																	____
		534																	____
		535																	____
		536																	____
		537																	____
		538																	____
		539																	____
		540																	____
		541																	____
		542																	____
		543																	____
		544																	____
		545																	____
		546																	____
		547																	____
		548																	____
		549																	____
		550																	____
		551																	____
		552																	____
		553																	____
		554																	____
		555																	____
		556																	____
		557																	____
		558																	____
		559																	____
		560																	____
		561																	____
		562																	____
		563																	____
		564																	____
		565																	____
		566																	____
		567																	____
		568																	____
		569																	____
		570																	____
		571																	____
		572																	____
		573																	____
		574																	____
		575																	____
		576																	____
		577																	____
		578																	____
		579																	____
		580																	____
		581																	____
		582																	____
		583																	____
		584																	____
		585																	____
		586																	____
		587																	____
		588																	____
		589																	____
		590																	____
		591																	____
		592																	____
		593																	____
		594																	____
		595																	____
		596																	____
		597																	____
		598																	____
		599																	____
		600																	____
		601																	____
		602																	____
		603																	____
		604																	____
		605																	____
		606																	____
		607																	____
		608																	____
		609																	____
		610																	____
		611																	____
		612																	____
		613																	____
		614																	____
		615																	____
		616																	____
		617																	____
		618																	____
		619																	____
		620																	____
		621																	____
		622																	____
		623																	____
		624																	____
		625																	____
		626																	____
		627																	____
		628																	____
		629																	____
		630																	____
		631																	____
		632																	____
		633																	____
		634																	____
		635																	____
		636																	____
		637																	____
		638																	____
		639																	____
		640																	____
		641																	____
		642																	____
		643																	____
		644																	____
		645																	____
		646																	____
		647																	____
		648																	____
		649																	____
		650																	____
		651																	____
		652																	____
		653																	____
		654																	____
		655																	____
		656																	____
		657																	____
		658																	____
		659																	____
		660																	____
		661																	____
		662																	____
		663																	____
		664																	____
		665																	____
		666																	____
		667																	____
		668																	____
		669																	____
		670																	____
		671																	____
		672																	____
		673																	____
		674																	____
		675																	____
		676																	____
		677																	____
		678																	____
		679																	____
		680																	____
		681																	____
		682																	____
		683																	____
		684																	____
		685																	____
		686																	____
		687																	____
		688																	____
		689																	____
		690																	____
		691																	____
		692																	____
		693																	____
		694																	____
		695																	____
		696																	____
		697																	____
		698																	____
		699																	____
		700																	____
		701																	____
		702																	____
		703																	____
		704																	____
		705																	____
		706																	____
		707																	____
		708																	____
		709																	____
		710																	____
		711																	____
		712																	____
		713																	____
		714																	____
		715																	____
		716																	____
		717																	____
		718																	____
		719																	____
		720																	____
		721																	____
		722																	____
		723																	____
		724																	____
		725																	____
		726																	____
		727																	____
		728																	____
		729																	____
		730																	____
		731																	____
		732																	____
		733																	____
		734																	____
		735																	____
		736																	____
		737																	____
		738																	____
		739																	____
		740																	____
		741																	____
		742																	____
		743																	____
		744																	____
		745																	____
		746																	____
		747																	____
		748																	____
		749																	____
		750																	____
		751																	____
		752																	____
		753																	____
		754																	____
		755																	____
		756																	____
		757																	____
		758																	____
		759																	____
		760																	____
		761																	____
		762																	____
		763																	____
		764																	____
		765																	____
		766																	____
		767																	____
		768																	____
		769																	____
		770																	____
		771																	____
		772																	____
		773																	____
		774																	____
		775																	____
		776																	____
		777																	____
		778																	____
		779																	____
		780																	____
		781																	____
		782																	____
		783																	____
		784																	____
		785																	____
		786																	____
		787																	____
		788																	____
		789																	____
		790																	____
		791																	____
		792																	____
		793																	____
		794																	____
		795																	____
		796																	____
		797																	____
		798																	____
		799																	____
		800																	____
		801																	____
		802																	____
		803																	____
		804																	____
		805																	____
		806																	____
		807																	____
		808																	____
		809																	____
		810																	____
		811																	____
		812																	____
		813																	____
		814																	____
		815																	____
		816																	____
		817																	____
		818																	____
		819																	____
		820																	____
		821																	____
		822																	____
		823																	____
		824																	____
		825																	____
		826																	____
		827																	____
		828																	____
		829																	____
		830																	____
		831																	____
		832																	____
		833																	____
		834																	____
		835																	____
		836																	____
		837																	____
		838																	____
		839																	____
		840																	____
		841																	____
		842																	____
		843																	____
		844																	____
		845																	____
		846																	____
		847																	____
		848																	____
		849																	____
		850																	____
		851																	____
		852																	____
		853																	____
		854																	____
		855																	____
		856																	____
		857																	____
		858																	____
		859																	____
		860																	____
		861																	____
		862																	____
		863																	____
		864																	____
		865																	____
		866																	____
		867																	____
		868																	____
		869																	____
		870																	____
		871																	____
		872																	____
		873																	____
		874																	____
		875																	____
		876																	____
		877																	____
		878																	____
		879																	____
		880																	____
		881																	____
		882																	____
		883																	____
		884																	____
		885																	____
		886																	____
		887																	____
		888																	____
		889																	____
		890																	____
		891																	____
		892																	____
		893																	____
		894																	____
		895																	____
		896																	____
		897																	____
		898																	____
		899																	____
		900																	____
		901																	____
		902																	____
		903																	____
		904																	____
		905																	____
		906																	____
		907																	____
		908																	____
		909																	____
		910																	____
		911																	____
		912																	____
		913																	____
		914																	____
		915																	____
		916																	____
		917																	____
		918																	____
		919																	____
		920																	____
		921																	____
		922																	____
		923																	____
		924																	____
		925																	____
		926																	____
		927																	____
		928																	____
		929																	____
		930																	____
		931																	____
		932																	____
		933																	____
		934																	____
		935																	____
		936																	____
		937																	____
		938																	____
		939																	____
		940																	____
		941																	____
		942																	____
		943																	____
		944																	____
		945																	____
		946																	____
		947																	____
		948																	____
		949																	____
		950																	____
		951																	____
		952																	____
		953																	____
		954																	____
		955																	____
		956																	____
		957																	____
		958																	____
		959																	____
		960																	____
		961																	____
		962																	____
		963																	____
		964																	____
		965																	____
		966																	____
		967																	____
		968																	____
		969																	____
		970																	____
		971																	____
		972																	____
		973																	____
		974																	____
		975																	____
		976																	____
		977																	____
		978																	____
		979																	____
		980																	____
		981																	____
		982																	____
		983																	____
		984																	____
		985																	____
		986																	____
		987																	____
		988																	____
		989																	____
		990																	____
		991																	____
		992																	____
		993																	____
		994																	____
		995																	____
		996																	____
		997																	____
		998																	____
		999																	____
		1000																	____
	Vendor Certification I certify that I am an authorized representative of the above-named vendor, that I have examined the information provided in the Rural Health Care Pilot Program Invoice, and to the best of my knowledge, information and belief, all costs contained in this invoice are true and correct and represent actual incurred costs for network build-out or related services received by each participating health care provider. Signature : _____________________________ Date : ________________________________ Phone# : _________________________ Print Name : _____________________________ Email : ________________________________ __________________________________________________________________________________________________________________________________________________________________________________ Project Coordinator Certification I certify that I have examined the information provided in the Rural Health Care Pilot Program Invoice, and to the best of my knowledge, information and belief, the participating health care providers have received the network build-out or related services itemized on this invoice. I certify under penalty of perjury that the 15 percent minimum funding contribution for each item on this invoice required by the Rural Health Care Pilot Program rules was funded by eligible sources as defined in the rules and has been provided to the vendor. Signature : _____________________________ Date : ________________________________ Phone# : _________________________ Print Name : _____________________________ Email : ________________________________

---

Sheet 3: Invoice Report

"FRN"

FRN

Template Invoicing Report

10000

20000

20000

FRN:

Total Amount Committed:

$-

Funding Year:

Total Amount Invoiced:

$-

Service Provider:

Total Amount Remaining:

$-

SPIN:

Report Date:

1/11/1981

NCW ID

Category

Sub-Category

Component

Speed

Comments

Num of Items Committed

Cost Per Item

Num of Items Invoiced

Num of Items Remaining

$ Committed

$ Invoiced

$ Remaining

Funding Year

SPIN

FRN

NCW ID

SP Name

Category

Sub-Category

Item

Speed

Comments

# Committed

Committed Cost

# Invoiced

# Remaining

Total $ Committed

Total $ Invoiced

Total $ Remaining