Fontana Unified School District
CONSULTANT REQUEST FOR PAYMENT
Today’s Date: Site/Dept.: Categorical Programs
Mail To: Fontana Unified School District Purchase Order No.:
Attn: Categorical Programs
P.O. Box 5090 Invoice #
Fontana, CA 92334-5090
From:
Consultant Name Address City State Zip
As per written agreement, payment is requested for consultant services.
Description of Consultant Services: Supplemental Educational Services (SES) Tutoring
Date(s) services were rendered:
This claim is for: partial payment ($ )
final payment ($ )
The following certification must be completed by individual consultants – consultant firms should disregard it.
I certify that I am , I am not (check one) drawing pay as a retired member of the California State Teachers’ Retirement System (STRS), or Public Employees Retirement System (PERS). If an employee of a federal, state, or local government agency; I certify that all services for which payment is now being claimed were rendered at times other than my regular assigned workday for that agency.
Signature of Consultant Social Security No./ Tax I.D. No.
OFFICE USE ONLY
I hereby certify that the above-named consultant has performed services as claimed and is entitled to payment in the amount of $______.
Signature-Principal/Administrator Date
Consultant Request for Payment Form
Rev. 9/20/2007