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For detailed instructions, Contact your CDPHE program.
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Colorado Department of Public Health and Environment
EXPENDITURE DETAILS for REIMBURSEMENT INVOICE FORM
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https://www.colorado.gov/pacific/cdphe/standardized-invoice-form-and-links
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Invoice #Organization Name
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FEINInvoice Period
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Purchase Order/
Encumbrance #		Final Invoice
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Payment Option
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To:Colorado Dept of Public Health and EnvironmentFrom:
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CDPHE Program:Contact Name:
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CDPHE Contact:Remit Address:
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Mail Code:
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Address:4300 Cherry Creek Drive South
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City:DenverCity:
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State:COState:
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Zip Code:80246Zip Code:
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Fax:Fax:
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Telephone:Telephone:
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Email:Email:
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Expenditure CategoriesMatch or In-Kind (If Applicable)Total Amount Requested from CDPHE
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Personal ServicesGross Earnings for invoice periodFringePercent of Actual Time on Contract/
Purchase Order
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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$0.00
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Totals - This line shows total salary / fringe with the % applied $0.00 $0.00
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Total Personal Services
(including fringe benefits)		$0.00 $0.00
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Supplies & Operating Expenses
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Total Supplies
& Operating Expenses		$0.00 $0.00
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Travel
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Total Travel$0.00 $0.00
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Other Costs
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Total Other Costs$0.00 $0.00
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Contractual (payments to third parties or entities)
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Total Contractual$0.00 $0.00
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SUB-TOTAL BEFORE INDIRECT$0.00 $0.00
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Indirect
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