Fillable OFFICE OF LANGUAGE ACCESS STATEMENT FOR SERVICES FAILURE (Administrative Office of the Courts)

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OFFICE OF LANGUAGE ACCESS STATEMENT FOR SERVICES FAILURE (Administrative Office of the Courts)

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BROWSE ADMINISTRATIVE OFFICE OF THE COURTS (KY) FORMS

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INVOICE(S) SHALL BE SUBMITTED WITHIN 7 DAYS OF THE SERVICE BEING PROVIDED.
FAILURE TO COMPLY WITH THIS REQUIREMENT MAY RESULT IN DELAY.
AOC-INT-1
Rev. 3-19
Page 1 of 2
Commonwealth of Kentucky
Court of Justice www.courts.ky.gov
AP Part IX, Sections 7 and 15; Uniform
Payment Rate for Freelance Interpreters
Sections I (1) and (2)
OFFICE OF LANGUAGE ACCESS
STATEMENT FOR SERVICES
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For Internal Use Only
Date Received by OLA: ______________
Time Period of Invoice:
From ____________ to _____________
Page _____ of ______
VERIFICATION OF APPOINTING/REQUESTING AUTHORITY
_______________________________________ ____________________________________________
Printed Name of Appointing/Requesting Authority Signature of Appointing/Requesting Authority
_______________________ ____________________, 2_____ _______________________________
County Date Title of Appointing/Requesting Authority
Contract #:___________________________ Invoice #: ____________ Assignment ID #: ___________________
Name of Interpreter: _________________________________ Language or Dialect Interpreted: __________________
Mailing Address: __________________________________ Phone Number: ______________________
__________________________________ Email Address: ________________________________
__________________________________ County of Residence/Business: ___________________
Total Interpreting Time: __________ hours X $ _____________ (See Contract Rate) = $ _________________
Court: __________________________ Court Address: ________________________________________________
Court: __________________________ Court Address: ________________________________________________
Total Travel Time: __________ hours X $ _____________ (See Contract Rate) = $ _________________
Total Reimbursable Lodging Expenses: (OLA Pre-Approval and Receipt Required) = $ _________________
Total # of Cases Included in this Invoice: ______ (enter “0” if none) INVOICE TOTAL: $ _________________
I hereby state the information provided on this form and the payment requested is true to the best of my knowledge.
Each charge is supported by relevant orders and receipts. NO OTHER INVOICE HAS BEEN SUBMITTED FOR THESE
SERVICES.
_____________________________, 2______ ____________________________________________
Date Interpreter Signature
VERIFICATION OF APPOINTING/REQUESTING AUTHORITY
_______________________________________ ____________________________________________
Printed Name of Appointing/Requesting Authority Signature of Appointing/Requesting Authority
_______________________ ____________________, 2_____ _______________________________
County Date Title of Appointing/Requesting Authority
( )
0
0
0
0
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Name of Interpreter: __________________________________________ Invoice #: _______________
Time Period of Invoice: From _______ to _______ Contract #: __________________________________ Page _______ of ________
Use as many page 2 of 2 pages as necessary 15 min. = .25; 30 min. = .5; 45 min. = .75
* Court Level: CC = Circuit Court; DC= District Court; FC = Family Court; SC = Specialty Court; PS = Pretrial Services; CDW = Court Designated Worker; OT = Other
Date of
Service
AOC-INT-1
Rev. 3-19
Page 2 of 2
County of
Service
Travel Time
(If Any)
Interpreting Time Total Time
(round to
nearest
1/4 hour)
Case Information
(or Description of Direct Service Provided)
Name of Person
Requiring Services
Case # Judge’s Last Name Court Level*
Start End Subtotal Start End Subtotal or
2 hr min.
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Date Service
Scheduled
Type of Service
Scheduled
Length of
Scheduled
Service
County of
Service
Date of
Cancellation
Compensation Name of
No-Show
Party
Hours Rate Total
Check if
No-Show
CANCELLATIONS/NO SHOWS
Submit by mail to: Administrative Oce of the Courts
Manager, Oce of Language Access
1001 Vandalay Drive, Frankfort, KY 40601
or by e-mail to: FreelanceInterpreterInvoices@kycourts.net.
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OFFICE OF LANGUAGE ACCESS STATEMENT FOR SERVICES FAILURE (Administrative Office of the Courts)

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Completed 27 January 2021

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