Voucher Form

Attachment VI voucherform.doc

Generic Clearance for Questionnaire Pretesting Research

Voucher Form

OMB: 0607-0725

Document [doc]
Download: doc | pdf

Standard Form 1034

September 1973

Treasury FRM 2000

PUBLIC VOUCHER FOR PURCHASES AND

SERVICES OTHER THAN PERSONAL

VOUCHER NO.

U.S. DEPARTMENT, BUREAU OR ESTABLISHMENT AND LOCATION


U.S. Department of Commerce

Bureau of the Census

Washington, DC 20233-9800

DATE VOUCHER PREPARED


SCHEDULE NO.

CONTRACT NUMBER AND DATE


PAID BY

REQ. NUMBER AND DATE


PLEASE PRINT NAME & ADDRESS BELOW:


PAYEE’S

NAME

AND

ADDRESS


DATE INVOICE RECEIVED


DISCOUNT TERMS


PAYEE’S ACCOUNT NUMBER


SHIPPED FROM TO WEIGHT


GOVERNMENT B/L NUMBER

NUMBER

AND DATE

OF ORDER

DATE OF DELIVERY OR SERVICE

ARTICLES OR SERVICES

(Enter description, item number of contract or Federal supply schedule,

and other information deemed necessary)



QUAN-TITY

UNIT PRICE

AMOUNT

COST

PER




For participating in interview as part of research on the CPS Food Security Supplement


Center for Behavioral Science and Measurement


Received by:______________________


Date: ________________________________________

















$40.00

(Use continuation sheet(s) if necessary) (Payee must NOT use the space below) TOTAL


PAYMENT:

COMPLETE

PARTIAL

FINAL

PROGRESS

ADVANCE

APPROVED FOR

$40.00

EXCHANGE RATE

= $1.00

DIFFERENCES


BY:


TITLE:

Amount verified correct for

$40.00

(Signature or initials)

Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment


_____________________ _______________________________________________________________________ ______________________________________________

(Date) (Authorized Certifying Officer) (Title)

ACCOUNTING CLASSIFICATION

Project/Task: 0906-000; Organizational Code: 11-09-0098-00-00-00-00; Obj. Class: 25-20-04-02

CHECK NUMBER ON TREASURER OF THE UNITED STATES

CHECK NUMBER ON (Name of Bank)


CASH DATE

PAYEE

PER

TITLE


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