DBHIDS - System of Care | E-INVOICE Submission Form

NOTE: If this is your first-time invoice submission; then please complete a W9 form.

Member Type*

Select or enter value

Name*

(First Name MI , Last Name)

Home Address*

Zip

City

Philadelphia

Telephone #*

Email*

Title of Meeting or Activity*

Select

Community Council Name *

Select a Community Council Name from the List or Select N/A if the title of meeting mentioned above is not a CCC Meeting

Select

Description of Meeting (if selected "OTHER" )

please provide a short description/title of meeting if selected "Other" . Please type N/A if listed a title for meeting.

Date of Meeting*

Date of Meeting / Activity

Meeting Start Time*

Select

AM/PM

Select

Total Meeting Hours*

Please select from drop -down list

Consultation Type

$ 30 ( for 0-3 Hrs)

Do you plan to attend Next Month's meeting at this Council ? ( Select 1 for Yes , 0 for No)*

Select

Is this your first submission for payment? If YES then please provide your W9 / contact one of the PSOC facilitators. please note that we need a copy of your signed W9 to process payments.*

Select

File Attachments ( attach receipts of parking or other related recipts or W9 (for first submission)

Drag and drop files here or

I understand that invoices must be received within 60 days of the date of service in order to receive payment.*

I confirm that the information given in this form is true, complete and accurate and I hereby authorize DBHIDS-SOC to verify and process my payment request ( Signed by - Print Your Name)*

Date of form Submission / Today's Date ( not Meeting /Event date)*

Send me a copy of my responses

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