/
Invoice and Certification
For Services of Independent Contractor/Consultant
ACCOUNT NO - OBJECT CODE
- /
AGREEMENT NUMBER
/
PEID #
/
PO #
NOTE: Agreement for services of Independent Contractor/ Consultant must be completed, processed and approved BEFORE this invoice may be processed.
/ FINAL PAYMENT YES NO
MAIL CHECK YES NO
CALL ______FOR PICKUP

PLEASE PRINT

TO BE COMPLETED BY INDEPENDENT CONTRACTOR/ CONSULTANT
A. / Name: / B. / Federal Employer ID Number:
C. / Address: / Incorporated? / No / Yes
Street # & Name / Sole Proprietor? / No / Yes
City, State, Zip / If Yes, provide FEID above
Country / and Sole Proprietor Name:
D. / Actual Date(s) Services Performed:
E. / Description of Services Performed: / F. Location:
G. / Payment Due For: / Hour(s)
Day(s) at
Task(s) / = Total of $
enter # of: / rate per hr/ day/ task
H. / I certify that the data supplied above is true and correct, that the services I have agreed to perform have been completed, and that this amount is not in excess of my normal charges for similar services. The working times involved were compatible with any and all other services for which I have received compensation from California State University, Sacramento and/or University Enterprises, Inc.
date / independent contractor/ consultant signature
PROJECT DIRECTOR APPROVAL:
I certify the services and fees as outlined above have been performed and are in accordance with the terms and conditions of an agreement for services which has been completed and filed.
I certify further that the funds for the services provided are available and are being expended in accordance with award guidelines.
Date: / Project Director Name
Project Director Signature
Date: / If Applicable
Funding Agency Approval Print Name
Funding Agency Approval Signature
for University Enterprises, Inc. use only
Disencumber: / Full
Account Administrator Approval / date / Partial
Tax W/H: YES NO / Not Encumbered

Consultant Invoice Rev 8/31/2017