attachment-17-rfb-2027-dph-01-formu-ct-inv2.pdf

VENDOR INVOICE FOR GOODS OR SERVICES

RENDERED TO THE STATE OF CONNECTICUT

CO - 17 REV. 10/2010

STATE OF CONNECTICUT

OFFICE OF THE STATE COMPTROLLER

ACCOUNTS PAYABLE DIVISION

VENDOR:

PLEASE COMPLETE THIS FORM AND SEND IT TO THE

DEPARTMENT BILLING ADDRESS SHOWN ON THE PURCHASE ORDER

VENDOR / PAYEE: FIELDS 9,10,14 and 18 ARE MANDATORY FOR PAYMENT

(1) BUSINESS UNIT NAME

(5) DOCUMENT DATE

(3) INVOICE NO. (4) INVOICE AMOUNT

(10)

(6) INVOICE DATE (7) ACCOUNTING DATE (8) RPT. TYPE (9) VENDOR FEIN/SSN ID / ADDRESS CODE

SHIPPING INFORMATION

(36) DATE SHIPPED (37) FROM - CITY / STATE (38) VIA - CARRIER (39) F.O.B.

(34) RECEIVING REPORT NO. (35) DATE(S) OF RECEIPT(S)

(32) COMMODITIES RECEIVED OR SERVICES RENDERED - SIGNATURE

PAYEE:

PAYEE:

ADDRESS:

ADDRESS:

ADDRESS:

STATE : ZIP CODE :

(13) VENDOR COMMENTS

(14)

GIVE FULL DESCRIPTION OF GOODS AND / OR SERVICES

(15) (16) (17) (18)

QUANTITY UNITS UNIT PRICE AMOUNT

(19) (20) (24)

ACCOUNT

(26)

BUSINESS UNIT USE ONLY

DEPARTMENTQUANTITY

PROJECT/

GRANT

CHARTFIELD

1 REFERENCE

(30) DEPARTMENT NAME AND ADDRESS

(2) BUSINESS UNIT NO.

(22) (27) (28) (29)(21)

FUND AMOUNT

(23)

SID

(25)

PROGRAM

CITY: COUNTRY:

BUDGET

(12)

VOUCHER DATE

(TO BE COMPLETED BY VENDOR)

(31) PO NO.

(33) PO BUSINESS UNIT

(11) VOUCHER NO.

PREPARED BY

CHARTFIELD

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