mdhhs-5974, procurement contract invoice

Michigan Department of Health and Human Services

(New 10-21)

section 1 – invoice information

Master Agreement (MA) Number	Delivery Order (DO) Number	Invoice Number	Invoice Date

Project or Service Description	Service From Date	Service To Date

Invoice Type (Select Only One) Original Additional Credit Final	Original MDHHS Receipt Date - MDHHS Use Only

section 2 - vendor information

Vendor Legal Name	SIGMA Vendor/Customer Number	Address Code

Alias/DBA	Email Address

Street Address	City	State	Zip Code

section 3 – commodity line description

COMMODITY LINE DESCRIPTION	UNITS	RATE	AMOUNT

$0.00
$0.00
$0.00
$0.00

TOTAL	$0.00

CERTIFICATION: I certify that I am authorized to sign on behalf of the contractor/vendor, this is an accurate statement of expenditures and collections for the report period, all applicable federal and state requirements have been complied with in administering the contract, allowable activities were provided to eligible clients, and only costs related to the services described in the contract were charged. Appropriate documentation is available and will be maintained for the reporting period to support costs and receipts submitted.

Vendor Authorized Name (Printed)	Vendor Authorized Signature	Date

FOR MDHHS USE ONLY

MDHHS Certification: I certify that the goods or services listed above have been received, are accurate in accordance with the terms and conditions of the contract and are approved for payment. Supporting documentation for the reporting period is available and will be maintained to support approval.

BSC Contract Administrator/Analyst	BSC Number

MDHHS Approval Name (Printed)	MDHHS Approval Signature	Date

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

INSTRUCTIONS FOR COMPLETING THE PROCUREMENT CONTRACT INVOICE

MA Number: Fill in the MA Number (Master Agreement Number). This number can be found on the Delivery Order under the Internal Use section. Example: 21*1234, where the “*” represents the series of “0”s in the MA number, 210000001234.

DO Number: Fill in the DO Number (Delivery Order Number). This number can be found on the upper left-hand corner of the Delivery Order as the Doc ID. Example: 21*4567, where the “*” represents the series of “0”s in the DO number, 21*0000004567.

Project or Service Description: Fill in the Service Description as it appears on the contract under the Contract Summary section. Example: Family Preservation – Advanced Parent Education Home Based.

Vendor Legal Name: Fill in the legal name of the vendor.

Invoice Number: Fill in a unique invoice number. This number must be different for each billing and can never be duplicated. If the vendor does not already have a unique invoice number, the vendor could use a number like the following example: 01/21 DO 21*1234, where 01/21 is the month of providing service of January of 2021 and DO 21*1234 is the Delivery Order number.

Invoice Date: Fill in the date the invoice is prepared.

Alias/DBA: Fill in the “Doing Business As” name used by the vendor if different than the Vendor Legal Name.

Service From Date: Fill in the first date of the billing period. Example: 06/01/21.

Service To Date: Fill in the last date of the billing period. Example: 06/30/21.

SIGMA Vendor/Customer Number: Fill in the SIGMA assigned Vendor/Customer Number. Example: CV1234567.

Address Code: Fill in the SIGMA Address Code which corresponds to the payment address that the payment should be remitted to. Example: 001.

Invoice Type (Select Only One): Indicate if the invoice is an original, additional, credit, or final. Please see “Revised Billings” below for additional and credit invoices. Please select final for the last invoice of the Delivery Order period, ensuring all outstanding issues have been resolved and all prior invoices have been paid.

Email Address: Fill in the vendor contact email address.

Street Address/City/State/Zip Code: Fill in the complete address that corresponds to the Address Code in SIGMA that the payment should be remitted to.

Commodity Line Description: Fill in the Commodity Line Description as found on the Delivery Order. Examples: Unit Rate, Transportation, Specific Assistance, etc.

Units: Fill in the number of units provided for each service during the billing period. For Unit Rate, enter the number of units provided as described in the contract (for example, number of hours). For Transportation, enter 1. For Specific Assistance, enter 1.

Rate: Fill in the payment rate for each service as stated in the contract under Schedule B – Pricing Matrix. For Unit Rate, enter the rate per unit (for example, 41 for $41.00/hour). For Transportation, enter the total amount of Transportation incurred for the billing period. For Specific Assistance, enter the total amount of Specific Assistance incurred for the billing period.

Amount: This is a formula that will automatically fill based on the entries in the Units and Rate boxes (Units multiplied by the Rate).

Vendor Authorized Name: Print the name of the person authorized to sign who is signing the billing on behalf of the vendor.

Vendor Authorized Signature/Date: Signature of the person certifying the billing on behalf of the vendor and the date signed.

TO BE COMPLETED BY LOCAL OFFICE

BSC Contract Administrator/Analyst: Print the name of the BSC Contract Administrator listed on the contract, or the BSC Contract Administrator currently managing the contract if different than listed on the contract.

MDHHS Approval Name: Print the name of the local office employee authorizing payment. This is the same person who is signing the invoice approving payment.

MDHHS Approval Signature/Date: Signature of the person certifying the billing on behalf of MDHHS, and the date signed.

BILLING SUBMISSION

Submit the Procurement Contract Invoice and all backup documents supporting the invoice to the County MDHHS Office.

REVISED BILLINGS

Revised billings are no longer accepted.

Additional: For charges that were not included on the initial billing but should have been, please submit the Procurement Contract Invoice for the ADDITIONAL CHARGES ONLY along with all backup documents supporting the invoice to the County MDHHS Office. As with all billings, only one billing period should be submitted on each Procurement Contract Invoice. Please note that the invoice number cannot be duplicated.

Credit: For charges that were included on the initial billing in error, please submit a negative Procurement Contract Invoice for the charges that should not have been billed along with all backup documents supporting the credit (refund) due to the vendor to the County MDHHS Office. As with all billings, only one billing period should be submitted on each Procurement Contract Invoice. Please note that the invoice number cannot be duplicated.