Vendor Payment Form
Yellowstone Country Assistance Network of Park County, Wyoming
Vendor/Contractor Information (Required)
Vendor/Company Name (Legal Name)
*
Name to be Written on the Check
Vendor FEIN/Tax ID
*
Vendor Contact Person
*
First Name
Last Name
Vendor Address (where the check will be mailed)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vendor Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Vendor Email
*
Providing your email allows us to better communicate payment status.
II. Payment Request Detailing
Client Information (CSBG Eligible Individual)
*
First Name
Last Name
Was this service or expense subsidized or covered by any other program (e.g., Child Care Vouchers, Medicaid/Healthcare, TANF, Utility Assistance, other grants or community programs)?
Yes
No
Invoice Number: (The vendor's unique invoice ID)
Invoice Date:
*
-
Month
-
Day
Year
Date
Invoice Total
*
Name of Other Subsidizing Program(s)
For the vendor to input the program name (e.g., "Child Care Voucher").
Other Program Paid Amount
Client Paid Amount
Calculation
Balance Requested from YCAN
Service Period: (Start Date and End Date of services being billed)
*
Type of Service Provided (Childcare for Employment, Auto Repair Service, Commercial Driver's License Training Course)
The services detailed in this payment request have been fully and accurately rendered to the named client.
*
The services detailed in this payment request have been fully and accurately rendered to the named client.
The information provided on this form is true and correct in its entirety.
I have not assisted the client in receiving this service or payment if I knew, or reasonably should have known, that the client was ineligible for the service.
The final requested payment amount represents the true and outstanding balance due to this vendor for the service provided to the eligible client, after accounting for all other subsidies, vouchers, and client payments.
This request is in compliance with all applicable federal, state, and local grant requirements, including those of the Community Services Block Grant (CSBG) program.
Vendor Signature
Date
*
/
Month
/
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: