DSMES Facilitator Invoice

Payment Request
Name
Address
City, ST Zip
Phone
Email
example@example.com
DSMES Location:
Name and Address
# Participants
# Graduated Participants
Facilitator(s)
Stat Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Contact: Moji Delano

Title: Faith & Diabetes Program Coordinator

Email: mdelano@ish-tmc.org

Phone: 713-797-0600 x5
DESCRIPTION
RATE
QUANTITY
AMOUNT
*Class Stipend (upon completion)
$25.00 each
Expense Reimbursements (include receipts)

*submit one invoice per course (6 classes)
Quantity
Amount
Grand Total
Date Request Submitted

MonthDayYear
Date
Make check payable to:
NOTES
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Payment Request