Attachment 3(E) - Standard Form 1034 SAMPLE.pdf

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

100 Main Street Courthouse Anywhere, USA PAYEE'S NAME AND ADDRESS: Vendor, Inc Lockbox 1234 Anywhere, USA Attn: Jim Doe