For Personal, Professional, Consulting or Social Service Contract

1. Contractor Name (To be appear exactly as typed on service contract)

2. Title Name Assigned to Contract or Brief Description of Service Contracted

3. Services Rendered And Approved For Payment (Complete A or B / Not Both)

A. The Contract Coordinator authorizes payment for completion of services rendered
for the maximum fee of [___________].

B. The Contract Coordinator authorizes payment for progress installment no. ____ for
services rendered to date in the amount of [___________].

C. Travel and other reimbursable expenses (mark one block only):

[____] Travel, lodging, meals and other expenses are NOT applicable to this contract,
or the maximum contract fee INCLUDED travel, lodging, meals and other expenses. Go
to Step 4.

[____] The maximum contract fee EXCLUDED travel, lodging, meals and other expenses.
All reimbursable expenses shall be paid in accordance with State of Louisiana Travel
Regulation (PPM 49).

Excluded reimbursable expenses were not to exceed: [_________]

* Total reimbursable expenses approved for payment: [_________] Go to Step 4.

* Note: The Contractor Coordinator shall require the Contractor to submit an itemized
original invoice for reimbursable expenses and any required receipts in accordance
with State Travel Regulations.

4. The Contract Coordinator affirms the contract services rendered to have been performed
satisfactorily and authorizes payment as outlined.