Fact Finding Invoice {PERA-47} | Pdf Fpdf Docx | Pennsylvania

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Fact Finding Invoice {PERA-47} | Pdf Fpdf Docx | Pennsylvania

Fact Finding Invoice {PERA-47}

This is a Pennsylvania form that can be used for Workers Comp.

Alternate TextLast updated: 7/17/2018

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FACT-FINDING INVOICE002 VENDOR INFORMATION LOCATION CODE: 12PLRB002 Name Vendor ID Address Invoice Number City State Zip Telephone Signature Date CASE INFORMATION002 Case Number Employer Employe Organization SERVICES PROVIDED002 Hearing date(s): Number of days: $ Preparation, research, writing date(s): Number of days: $ EXPENSES002 Mileage: miles @ $/mile $ Parking and tolls $ Lodging $ Subsistence $ Postage/Mailing $ Miscellaneous (please explain): $ PLEASE SEND YOUR INVOICE TO THIS ADDRESS: Pennsylvania Labor Relations Board 12PLRB PO Box 69181 Harrisburg, PA 17106 TOTAL: $ 002 AMOUNT BILLED TO COMMONWEALTH002 OF PENNSYLVANIA (50% OF TOTAL):002 $ 002 Third Party Responsibility 226 NOT billed to Commonwealth of Pennsylvania *Amount Billed to Public Employer (25% of total) $ *MAIL PAYMENTDIRECTLY TO FACT-FINDER *Amount Billed to Employe Organization (25% of total) $ Pennsylvania Labor Relations Board 651 Boas Street, Room 418 | Harrisburg, PA 17121-0750 | 717.787.1091 | F 717.783.2974 | www.dli.pa.gov Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com

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