STATE OF OKLAHOMA DEPARTMENT OF HUMAN SERVICES
ADULT DAY SERVICE INVOICE
Aging Services Division
State Department No. 830
Date:
IDENTIFYING INFORMATION:
Fed. ID:
Contract No.:
Contractor:
Address:
Street-Box
City
State
Zip
Location
PART I. CLAIMED ITEMS:
Purchase of Adult Day Services for the Calendar Month of:
Month Year
Total Number of Persons Claimed:
Amount Claimed: $
PART II. AUDIT APPROVAL: Reserved for approving office use only.
Number of Persons Disallowed by Approving Officer
Amount Disallowed$
Number of Persons Approved
Allowed Amount $
Unit Approval
Title and Location
Date
The undersigned (contractor) of lawful age, states (s)he has full knowledge of the above and foregoing account, that said account is just, true, correct, due and according to law, and that theamount claimed, after allowing all just claims, is now due and wholly unpaid. Contractor further states thatthe (work, services, or materials) as shown by this invoice or claim have been(completed or supplied), in accordance with the contract and program guidelines. Contractor further states that (s)he has made no payment, given, donated or agreed to pay, give or donate,either directly or indirectly, to any elected official, officer or employee of the State of Oklahoma,money or any other thing of value to obtain payment of the ward of this contract and that (s)he is duly authorized to make this claim.
Contractor Signature
Date
FOR STATE OFFICE USE ONLY: Officer’s Approval.
Approved on Fund:
Function: F
Agency: 830
Account:2861.
Amount $
Date:
“NOTICE: The Oklahoma Department of Human Services has assured compliance with DHHS Regulations, Title 45, Code of Federal Regulations Part 80 (which implements Public Law 88-352 Civil Rights Act of 1964, Section 601), Part 84 (which implements Public Law 93-112, Rehabilitation Act of 1973, Section 504), and Part 90 (which implements Public Law 94-135, Age Discrimination Act of 1975, Section 301). These laws and regulations prohibit excluding from participation in, denying the benefits of, or subjecting to discrimination under any program or activity receiving Federal Financial Assistance any person on the grounds of race, color, or national origin or any qualified person on the basis of handicap or unless program-enabling legislation permits, on the basis of age. Under these requirements, payment cannot be made to vendors providing care and/or services under Federally-assisted programs conducted by the Department unless such care and/or service is provided without discrimination on the grounds of race, color, national origin or handicap or without distinction on the basis of age except as legislatively permitted or required. Written complaints of noncompliance with any of these laws should be made to the Director of Human Services, P.O. Box 25352, Oklahoma City, Oklahoma 73125, or the Secretary of Health and Human Services, Washington D.C. or both.
OKLA. DHS ISSUED 7-1-2000 02AS001E (ADM-12-ADS-SI)
