PERSONAL SERVICE CONTRACT INVOICE FORM

GOVERNMENT CONTRACT REVIEW COMMITTEE

LEGISLATIVE RESEARCH COMMISSION

Pursuant to KRS 45A.695, no payment shall be made on any personal service contract unless the individual, firm, partnership, or corporation awarded the personal service contract submits its invoice for payment on a form established by the committee.

Invoices shall be submitted every ninety (90) days, unless the personal service contract specifies a different submission time period.

Separate invoices shall be submitted for each distinct matter covered by the personal service contract, and shall be signed by the individual responsible for that matter

The issuance of an invoice to the Commonwealth constitutes an affirmation by the individual, firm, partnership, or corporation awarded the personal service contract that the invoice truly and accurately represents work actually performed, and the expenses actually incurred.

The head of the contracting body shall approve the invoice, indicating that the charges in the invoice reflect the value of the work performed, and all recorded costs and disbursements were reasonably and necessarily incurred in connection with the matter invoiced.

NOTE: All questions must be answered fully. If the space provided is insufficient, additional pages should be attached referencing the specifically numbered item. Any questions regarding the invoice requirements should be directed to the contracting agency.

Contract Number: ______________________	Date of Invoice: ________________

___________________________________ _________________________________

Contracting Body	Division, Branch, etc.

1. Name & Address of Contractor:

2. Contractor’s Tax I.D. Number: _______________

3. Effective Period of Contract:	4. Combined Total Amount Charged in this

Starting Date: _____________	Invoice for Services and Reimbursable

Ending Date: _____________	Disbursements: ___________________

5. Dates of Service Covered under	6. Is this the FINAL invoice

this invoice:	for services performed

Starting Date: _____________	under this contract:

Ending Date: _____________	_____ Yes ______ No

7. Date of most recent invoice submitted prior to this invoice: ________________

8. How often is the contractor required to submit invoices under the terms of the personal service contract:

9. Provide a description of the matter covered by this invoice:

10. Provide a full description of each service provided, including the date each service was performed, the name and title of each individual who worked on the matter, and the time the individual spent on the matter:

11. Provide the hourly rate for each individual working on the matter and the total charge for that individual for each matter involved:

12. Provide the subject matter and recipient of any correspondence:

13. Provide a full description of any work product produced, designating the way in which the work product is associated with the matter being invoiced. (Attorneys Billing for Legal Services: If you contend that any information is subject to privilege, please identify the privileged item, and provide sufficient information to evaluate the claim of privilege):

14. Provide an itemized list of all disbursements to be reimbursed by the state for each matter invoiced and the total charge for that matter:

SIGNATURES:

Contractor: ___________________________	Date: _______________

Title: _________________________________

Contracting Body

Approved by: _________________________	Date: _______________

Title: ________________________________