Attachment J-12 - Appendix B - SF 1034 - Final.pdf
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- Solicitation number
- FTA_2024_PMO_0005
About this file
This document is a Standard Form 1034 template for public vouchers for purchases and services other than personal. It provides instructions and an example for submitting invoices and payment requests to the Federal Transit Administration. Key details include claiming total costs incurred during the period of performance by attaching supporting documentation, certifying the voucher is correct and proper for payment, and including accounting classification information. The related solicitation seeks proposals for project management oversight services in support of FTA grant programs, with responses due by a specified date. Award is anticipated at a future date.
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RFP Number 69319524R000001
Attachment J-12 Appendix B - SF 1034
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.
Standard Form 1034 Revised October 1987 Department of the Treasury
1 TFM 4-2000
PUBLIC VOUCHER FOR PURCHASES AND
SERVICES OTHER THAN PERSONAL
VOUCHER NUMBER
Start with 1, end with
FINAL
U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION
Federal Transit Administration Acquisition Division, TAD-40 1200 New Jersey Avenue, SE Washington, DC 20590
DATE VOUCHER PREPARED
Date Submitted in eInvoice
SCHEDULE NUMBER
Leave Blank
CONTRACT NUMBER AND DATE
TO and Mod #, Date of last Mod
PAID BY
Leave Blank
REQUISITION NUMBER AND DATE
Requisition # of Base Order
Name and address of contractor as it appears on the PAYEE'S contract
NAME
AND
ADDRESS
DATE INVOICE RECEIVED
Leave Blank
DISCOUNT TERMS
Leave Blank
PAYEE'S ACCOUNT NUMBER
Leave Blank
SHIPPED FROM TO WEIGHT
Leave Blank Leave Blank Leave Blank
GOVERNMENT B/L NUMBER
Leave Blank
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 Total cash billed (1)
Leave Blank Inv PoP For detail, see the total amount of the claim transferred from the attached documents, pages 2 through N.
COST REIMBURSABLE-PROVISIONAL PMT
(Use continuation sheet(s) if necessary) (Payee must NOT use the space below) TOTAL
PAYMENT:
PROVISIONAL
COMPLETE
PARTIAL
FINAL
PROGRESS
ADVANCE
APPROVED FOR
EXCHANGE RATE
=$1.00
DIFFERENCES
BY 2
Amount verified; correct for payment
TITLE (Signature or initials)
Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment.
(Date) (Authorized Certifying Officer) 2 (Title)
ACCOUNTING CLASSIFICATION
P A I D
B Y
CHECK NUMBER ON ACCOUNT OF U.S. TREASURY CHECK NUMBER ON (Name of bank)
CASH DATE
PAYEE 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
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Attachment J-12 - Appendix B - SF 1034
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