PPE Grant Reimbursement Invoice

Reimbursement Quarter: Q4 (January, February, March 2023)                       Date:
                                                                                                               Invoice #:
Bill From 
Contact name:
Contact phone/email:

Send Reimbursement To
Attn:
Facility/County (adult, juvenile or alternative):
Address:
City, State, Zip:

Bill To
Aelysea Webb
New Mexico Counties 
444 Galisteo St. 
Santa Fe, NM 87501
awebb@nmcounties.org; (505) 395-3403

1.	Number each submitted receipt and add to column below. (Include all receipt copies with invoice.)
2.	Add date of corresponding receipt.
3.	List PPE items purchased: rapid tests, gloves, masks, etc. 
4.	Note quantity purchased, unit price paid and invoice amount.
5.	Add each invoice amount for the total amount requested from NMC.	
Receipt Number	Receipt Date	Test or PPE Item 	Qty	Unit Price Paid for Tests or PPE	Invoice Amount	

						

						
						
Total attached invoices:		
                                                                                  Total reimbursement request:
 (Cannot exceed grant allocation)