2023 HSMTA Adjudicator Invoice Form
All payments will be made via check that will be mailed to the mailing address inputted below. Broadway Dallas will do it's best to process all invoices in a timely manner. Adjudicators should expect to receive payment 3-4 weeks after invoice submission.
Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Adjudication Payment
School
Date (MM/DD/YYYY)
Rate ($)
School #1
School #2
School #3
School #4
School #5
School #6
Total Adjudication Payment Owed
Mileage Payment (*Proof of tolls must be uploaded at the bottom of the form)
Starting Location
Ending Location
Date (MM/DD/YYYY)
# of Miles
Tolls*
School #1
School #2
School #3
School #4
School #5
School #6
Total Mileage Payment Owed
Total Amount Owed
Proof of Tolls
Browse Files
Cancel
of
Judge Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: