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Attachment C
<br />Sample Invoice with Match (on vendor letterhead)
<br />ADDRESS:
<br />Send to the address of the contact Invoice Date: MM /DD/YY
<br />person on the contract. Invoice #: #####
<br />Payment amount for Performance Period: $5,865.00
<br />(Total Costs in Column B, Expenditure Categories)
<br />RE: Contract #
<br />Performance Period: MM /DD/YY through MM /DD/YY
<br />(same as Performance Period in Column B)
<br />Match Expenditures
<br />Salaries
<br />(A)
<br />(B)
<br />(C)
<br />(D)
<br />Fringe Benefits
<br />$2,500.00
<br />Performance
<br />$500.00
<br />$2,000.00
<br />Professional and Contracted
<br />Period for
<br />Services
<br />$5,000.00
<br />MM /DD/YY
<br />$2,000.00
<br />Balance of
<br />Travel
<br />Contract
<br />through
<br />Cumulative
<br />Budget as of
<br />Expenditure Categories
<br />Budget
<br />MM /DD/YY
<br />Expenses
<br />MM /DD/YY
<br />Salaries
<br />$10,000.00
<br />$2,000.00
<br />$2,000.00
<br />$8,000.00
<br />Fringe Benefits (25 %) *
<br />$2,500.00
<br />$500.00
<br />$500.00
<br />$2,000.00
<br />Professional and Contracted
<br />$3,900.00
<br />$765.00
<br />$765.00
<br />$3,135.00
<br />Services
<br />$5,000.00
<br />$2,000.00
<br />$2,000.00
<br />$3 „000.00
<br />Travel
<br />$1,000.00
<br />$200.00
<br />$200.00
<br />$800.00
<br />Supplies
<br />$2,500.00
<br />$400.00
<br />$400.00
<br />$2,100.00
<br />Equipment
<br />$5,000.00
<br />$0.00
<br />$0.00
<br />$5,000.00
<br />Total Direct Costs
<br />$26,000.00
<br />$5,100.00
<br />$5,100.00
<br />$20,900.00
<br />Indirect (if allowable) 15% *
<br />$3,900.00
<br />$765.00
<br />$765.00
<br />$3,135.00
<br />Total Costs
<br />$29,900.00
<br />$5,865.00
<br />$5,865.00
<br />$24,035.00
<br />Match Expenditures
<br />Salaries
<br />$10,000.00
<br />$2,000.00
<br />$2,000.00
<br />$8,000.00
<br />Fringe Benefits
<br />$2,500.00
<br />$500.00
<br />$500.00
<br />$2,000.00
<br />Professional and Contracted
<br />Services
<br />$5,000.00
<br />$2,000.00
<br />$2,000.00
<br />$3,000.00
<br />Travel
<br />$1,000.00
<br />$200.00
<br />$200.00
<br />$800.00
<br />Supplies
<br />$2,500.00
<br />$400.00
<br />$400.00
<br />$2,100.00
<br />Equipment
<br />$5,000.00
<br />$0.00
<br />$0.00
<br />$5,000.00
<br />Total Direct Costs
<br />$26,000.00
<br />$5,100.00
<br />$5,100.00
<br />$20,900.00
<br />Indirect (if allowable)
<br />$3,900.00
<br />$765.00
<br />$765.00
<br />$3,135.00
<br />Total Costs
<br />$29,900.00
<br />$5,865.00
<br />$5,865.00
<br />$24,035.00
<br />* Fringe Rates & Indirect Rates must be approved in
<br />the grant application process with TPWD.
<br />I, subrecipient/vendor, certify that this invoice is correct and that matching funds (if required in the contract) have been
<br />provided and will be subject to audit under OMB Circular A -133. 1 further certify that this invoice has not been previously paid.
<br />Page 9
<br />PWD 8 A1500- (01/2011)
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