sf1034.pdf
PDF 308 KB Posted
- Attached to
- Tuberculosis Epidemiology Studies Consortium Federal contract opportunity
- Solicitation number
- 2011-N-13311
About this file
J3 SF 1034 - Public Voucher Form
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Amendment 2.pdf | ||
| Amendment - TBESC 2011-N-13311.JPG | JPG image | |
| Cover Letter to RFP 2011-N-13311 | — | |
| TBESC Cover Letter SOW TO 1.pdf | ||
| 2011-N-13311 - RFP - TBESC.pdf | ||
| J5.pdf | ||
| ACH Vendor Form.pdf | ||
| Attachment J2 - Contractor Performance Report.docx | DOCX document | |
| Attachment J4 - Billing Instructions.docx | DOCX document |
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Text version
PUBLIC VOUCHER FOR PURCHASES AND
SERVICES OTHER THAN PERSONAL
VOUCHER NO.
U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION DATE VOUCHER PREPARED
CONTRACT NUMBER AND DATE
REQUISITION NUMBER AND DATE
SCHEDULE NO.
PAID BY
DATE INVOICE RECEIVED
DISCOUNT TERMS
PAYEE'S ACCOUNT NUMBER
GOVERNMENT B/L NUMBERSHIPPED FROM TO WEIGHT
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
COST PER
AMOUNT
(Use continuation sheet(s) if necessary) (Payee must NOT use the space below) TOTAL
DIFFERENCES
PAYMENT: APPROVED FOR EXCHANGE RATE
BY
TITLE
Amount verified; correct for payment
(Signature or initials)
=$ =$1.00
Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment.
(Date)
ACCOUNTING CLASSIFICATION
P A I D
CHECK NUMBER
CASH
ON ACCOUNT OF U.S. TREASURY
DATE
CHECK NUMBER
PAYEE
ON (Name of bank)
PER
TITLE
NSN 7540-00-900-2234
Standard Form 1034 Revised October 1987 Department of the Treasury
1 TFM 4-2000
PAYEE'S
NAME
AND
ADDRESS
NUMBER AND DATE
OF ORDER (1)
PROVISIONAL
COMPLETE
PARTIAL
FINAL
PROGRESS
ADVANCE
(Title)(Authorized Certifying Officer)
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.
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.
B Y
PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL
VOUCHER NO.
U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION
DATE VOUCHER PREPARED
CONTRACT NUMBER AND DATE
REQUISITION NUMBER AND DATE
SCHEDULE NO.
PAID BY
DATE INVOICE RECEIVED
DISCOUNT TERMS
PAYEE'S ACCOUNT NUMBER
GOVERNMENT B/L NUMBER
SHIPPED FROM
TO
WEIGHT
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
COST
PER
AMOUNT
(Use continuation sheet(s) if necessary) (Payee must NOT use the space below)
TOTAL
DIFFERENCES
PAYMENT:
APPROVED FOR
EXCHANGE RATE
BY
TITLE
Amount verified; correct for payment (Signature or initials) =$1.00 Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment.
(Date)
ACCOUNTING CLASSIFICATION
P A I D
CHECK NUMBER
CASH
ON ACCOUNT OF U.S. TREASURY
DATE
CHECK NUMBER
PAYEE
ON (Name of bank)
PER
TITLE
NSN 7540-00-900-2234
Standard Form 1034 Revised October 1987 Department of the Treasury 1 TFM 4-2000
PAYEE'S NAME AND ADDRESS
NUMBER AND DATE OF ORDER
(1)
PROVISIONAL
COMPLETE
PARTIAL
FINAL
PROGRESS
ADVANCE
(Title) (Authorized Certifying Officer) 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.
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.
B Y
| Voucher Number: |
| Paid By: |
| Contract Number and Date: |
| U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION: |
| PAYEE'S NAME AND ADDRESS: |
| Requisition Number and Date: |
| Shipped From: |
| To: |
| Weight: |
| Discount Terms: |
| Payee's Account Number: |
| Government B/L Number: |
| Date Invoice Received. Enter 2 digit month, 2 digit day and 4 digit year.: |
| Date Voucher Prepared. Enter 2 digit month, 2 digit day and 4 digit year.: |
| Number and Date of Order. Line 9 of 9.: |
| ARTICLES OR SERVICES. (Enter description, item number of contract or Federal supply schedule, and other information deemed necessary).: |
| Per: |
| Authorized Certifying Officer: |
| Check Number: |
| On (Name of bank): |
| Payee 3: |
| FOR: |
| Title: |
| Accounting Classification: |
| By 2: |
| Date of Delivery or Service. Enter 2 digit month, 2 digit day and 4 digit year.: |
| Date Certified. Enter 2 digit month, 2 digit day and 4 digit year.: |
| Date. Enter 2 digit month, 2 digit day and 4 digit year.: |
| Unit Price. Cost.: |
| Amount: |
| Amount: |
| Amount: |
| Amount: |
| Amount: |
| Amount: |
| Amount: |
| Amount: |
| Amount: |
| Total Amount: |
| Unit Price. Cost.: |
| Unit Price. Cost.: |
| Unit Price. Cost.: |
| Unit Price. Cost.: |
| Unit Price. Cost.: |
| Unit Price. Cost.: |
| Unit Price. Cost.: |
| Unit Price. Cost.: |
| Amount verified; correct for payment: |
| Cash: |
| Provisional: 0 |
| Complete: 0 |
| Partial: 0 |
| Final: 0 |
| Progress: 0 |
| Advance: 0 |
| Signature or initials. This is a protected field.: |
| When stated in foreign currency, insert name of currency: |
| Quantity: |
| Quantity: |
| Quantity: |
| Quantity: |
| Quantity: |
| Quantity: |
| Quantity: |
| Quantity: |
| Quantity: |
| APPROVED FOR: |
| DIFFERENCES, entry one of two: |
| DIFFERENCES, entry two of two: |
| Exchange Rate = $1.00: |
| Approved For = $: |
File details come from the government source that posted it. Updated .