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pdfStandard Form 1034
Revised October 1987
Department of the Treasury
1 TFM 4-2000
VOUCHER NUMBER
PUBLIC VOUCHER FOR PURCHASES AND
SERVICES OTHER THAN PERSONAL
U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION
DATE VOUCHER PREPARED
SCHEDULE NUMBER
CONTRACT NUMBER AND DATE
PAID BY
REQUISITION NUMBER AND DATE
PAYEE'S
NAME
AND
ADDRESS
DATE INVOICE RECEIVED
DISCOUNT TERMS
PAYEE'S ACCOUNT NUMBER
SHIPPED FROM
NUMBER AND DATE
OF ORDER
TO
DATE OF
DELIVERY
OR SERVICE
ARTICLES OR SERVICES
(Enter description, item number of contract or Federal supply schedule,
and other information deemed necessary)
(Use continuation sheet(s) if necessary)
PAYMENT:
PROVISIONAL
COMPLETE
PARTIAL
WEIGHT
QUANTITY
ADVANCE
UNIT PRICE
TOTAL
EXCHANGE RATE
=$
PER
COST
(Payee must NOT use the space below)
APPROVED FOR
=$1.00
DIFFERENCES
BY 2
FINAL
PROGRESS
GOVERNMENT B/L NUMBER
Amount verified; correct for payment
(Signature or initials)
TITLE
Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment.
(Authorized Certifying Officer) 2
(Date)
(Title)
ACCOUNTING CLASSIFICATION
P
A
I
D
B
Y
CHECK NUMBER
ON ACCOUNT OF U.S. TREASURY
CHECK NUMBER
CASH
$
DATE
PAYEE
ON (Name of bank)
3
1. When stated in foreign currency, insert name of currency.
2. If the ability to certify and authority to approve are combined in one person, one signature only is necessary; otherwise the approving
officer will sign in the space provided, over his official title.
3. When a voucher is receipted in the name of a company or corporation, the name of the person writing the company or corporate
name, as well as the capacity in which he signs, must appear. For example: "John Doe Company, per John Smith, Secretary", or
"Treasurer", as the case may be.
PER
TITLE
Previous edition usable
PRIVACY ACT STATEMENT
The information requested on this form is required under the provisions of 31 U.S.C. 82b and 82c, for the purpose of disbursing Federal
money. The information requested is to identify the particular creditor and the amounts to be paid. Failure to furnish this information will
hinder discharge of the payment obligation.
AMOUNT
(1)
File Type | application/pdf |
File Modified | 2016-05-10 |
File Created | 2016-05-10 |