SCHEDULE J FORM OF COMPANY INVOICE

TO: THE Agency 
Billing Month Number: 
Date of Submission: 
Date of Receipt: 
Due Date:

1.  Company Fee Computation

2.  Computation of Penalties Applicable to Billing Month

3.  Computation of Total Amount Due

4.  Payment Instructions

Received and Acknowledged by the Agency:

__________________________
Name:
Title:
Date: