Vendor Name and Address                                                                                        ADP Vendor Invoice 
                           Vendor Information 
                           ADP Vendor Registration Number
                           ADP Vendor Name
                           Invoice Information
                           ADP Claim Number
                           Vendor Invoice Number                                              Invoice Date (yyyy/mm/dd)        _____/___/___
                           Client Information
                           Client Health Number                                               Version:
                           Client Name (Last Name, First Name)
                           Client Address
                           Benefit Program                              Check      one only:
                                                                               Ontario Works Program (OWP)                 Ontario Disability Support Program (ODSP)
                                                                               Assistance to Children with Severe Disabilities (ACSD)
                           Equipment Specifications
                           Device              ADP               Description of Item                Serial        Quantity   Unit       Total      ADP         Client 
                           Placement           Catalogue         (Make & Model)                     Number                   Price      Price      Portion     Portion
                           (Left, Right, N/A)  Number
                                                                                                                       Invoice Totals
                           Proof of Delivery 
                           I hereby confirm that I have received the equipment described above and that I have received a fully itemized invoice from the vendor for the devices described
                           above.  
                           Client Signature                                                         Date of delivery (yyyy/mm/dd):   _____/___/___
                           Ministry of Health and Long-Term Care
                           Financial Management Branch
                           49 Place d'Armes, 2nd Floor
                           Kingston, ON, K7L 5J3