CS-65 (04/07)

CHILDREN’S SERVICES INTEGRATED

PAYMENT SYSTEM INVOICE FORM

DVN (9 digits)	COUNTY FIPS CODE (3 digits)	VENDOR TYPE (2 digits)	PROGRAM AREA (2 letter code)	WORKER ID NUMBER (5 digits)
NAME OF VENDOR	(7) STREET ADDRESS	CITY	STATE	ZIP CODE
(11) NAME OF CLIENT	(12) DCN (8 digits)	(13) SERVICE MONTH AND YEAR (MM/YYYY)	(14) FUND CATEGORY (2 digits)	(15) SERVICE CODE (4 letter code)	(16) TOTAL UNITS	(17) UNIT RATE	(18) TOTAL AMOUNT	(19) STATE OFFICE USE ONLY
(A)	$ 0.00
(B)	$ 0.00
(C)	$ 0.00
(D)	$ 0.00
(E)	$ 0.00
(F)	$ 0.00
(G)	$ 0.00
(H)	$ 0.00
(I)	$ 0.00
(J)	$ 0.00
(K)	$ 0.00
(L)	$ 0.00
(20) VERIFICATION SIGNATURE: DATE:	TOTAL:	$ 0.00
(21) SUPERVISOR APPROVAL SIGNATURE: DATE:
(22) ENTRY SIGNATURE: DATE: