General Vendor Invoice Template

This invoice sample is intended to be a resource to assist in the invoicing process by detailing the minimum requirements of a proper invoice. Invoices can be submitted in different layouts as long as all of this information is provided.


Sample Vocational Rehabilitation Vendor Invoice


General Vendor Invoice Template - Instructions

(Numbers correspond with those listed in the sample invoice)

1. Vendor Information

Vendor name, address, phone number(s), and IRS Federal Tax I.D. Number (FEIN or SS#). The information provided must match the vendor information on file with DOR; for any required changes submit a revised STD 204 with the invoice. Failure to include the most current business and/or payment address may result in misdirected mail and payment delays.

2. Invoice Number

A unique reference number automatically assigned by the vendor’s accounting system. Used to correspond regarding the invoice.

3. Invoice Date

Enter invoice issue date

4. Bill To

Enter the DOR District Office "Bill To" address listed on the authorization.

5. Consumer Name

Enter the name(s) of consumer(s) for which you provided goods or services.

6. DOR Authorization Number

Enter the DOR authorization number for each consumer listed on the invoice – the number begins with NMED, MED, or PO.

7. Description

Enter a brief description of the goods or services provided to the consumer.

8. Service Date

Enter the date or month the good or service was provided to the consumer.

9. Payment Breakdown

Enter actual hour(s)/unit(s) provided, pre-approved rate(s), and the subtotal for each good or service for each consumer.

10. Total

Enter the total amount for all goods and services provided or delivered to all consumers.

11. Supplemental Costs

Enter sales taxes, shipping, handling, or other pre-approved related costs not included in the per unit charge costs, as applicable. If costs are for different items, these must be included separately for confirmation of approved costs. For travel costs, enter separate line item for billable miles, cost per mile, allowable travel cost, and Travel Costs Subtotal.

12. Amount Due

Enter the grand total owed.

13. Signature and Date

The authorized vendor representative signs the invoice.