ATTACHMENT 3a SF-1034 CDRL 1 example.pdf

Standard Form 1034 Revised October 1987 Department of the Treasury

1 TFM 4-2000

1034-122

PUBLIC VOUCHER FOR PURCHASES AND

SERVICES OTHER THAN PERSONAL

VOUCHER NO.

U.S.DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION DATE VOUCHER PREPARED SCHEDULE NO.

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 TO WEIGHT

GOVERNMENT B/L NUMBER

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 (1)

(Use continuation sheets if necessary) (Payee must NOT use the space below) TOTAL

PAYMENT: APPROVED FOR EXCHANGE RATE DIFFERENCES

PROVISIONAL =$ =$1.00

COMPLETE BY2

PARTIAL

FINAL Amount verified; correct for

PROGRESS TITLE (Signature or initials)

ADVANCE

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

CHECK NUMBER ON ACCOUNT OF U.S. TREASURY CHECK NUMBER ON (Name of bank)

CASH DATE PAYEE3

When stated in foreign currently, insert name of currency.

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.

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 NSN 7650-00-634-4206

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.

ATTACHMENT 3a