CONCILIATION INVOICE PLEASE SEND YOUR INVOICE TO THIS ADDRESS: Pennsylvania Labor Relations Board 12PLRB PO Box 69181 Harrisburg, PA 17106 VENDOR INFORMATION Name Address City Signature CASE INFORMATION Case Number Employer Employe Organization SERVICES PROVIDED Date(s) of settlement or consultation time: State Purchase Order No.: Vendor ID Invoice Number Zip Telephone Date Number of hours: __________ @ $50/hour Date(s) of correspondence and telephone calls: $ Number of hours: __________ @ $50/hour Date(s) of preparation, research, writing: $ Number of hours: __________ @ $50/hour Total Number of Hours: __________ @ $50/hour NOTE: Hours must be reported in quarter-hour increments. $ $ EXPENSES Mileage: __________miles @ $__________/mile Parking and tolls Lodging Subsistence Postage/Mailing Miscellaneous (please explain): Total Expenses TOTAL AMOUNT (Hours + Expenses) $ $ $ $ $ $ $ $ Pennsylvania Labor Relations Board 651 Boas Street, Room 418 | Harrisburg, PA 17121-0750 | 717.787.1091 | F 717.783.2974 | www.dli.pa.gov PERA-50 REV 12-16 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com