ESBD_428405_1750275050893_Exhibit J - Sample Form 4116X.pdf
PDF 130 KB Posted
- Attached to
- FY26 APS Claims Processing
- Solicitation number
- HHS0016010
- Issued by
- Travis County, Austin City, Texas
About this file
The document is a blank Texas Department of Family and Protective Services (TDFPS) Purchase Voucher (Form 4116-Xe/9-15), which is an official state financial document used for processing payments. The form contains multiple sections for capturing detailed financial transaction information, including reference numbers, agency details, payee identification, invoice descriptions, and certification statements for goods or services rendered.
The voucher includes extensive fields for tracking financial transactions, with space for up to three separate invoice entries, comprehensive accounting codes, and mandatory certification language. The form requires signatures from authorized personnel and includes a subrecipient certification statement that emphasizes legal compliance and potential penalties for fraudulent reporting, specifically referencing U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812. While the form is currently blank, it is designed to support precise documentation of financial transactions for the Texas state government.
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Text version
Form 4116-Xe/9-15
STATE OF TEXAS
PURCHASE VOUCHER (Shaded Areas Not Used by Agency 530) Page of
1. Active Reference Number 2. Agency Number 3. Agency Name 4. Current Document Number
530 TEXAS DEPT OF FAMILY AND PROTECTIVE SERVICES
5. Effective Date 6. Order (document) Date 7. Due Date 8. Doc Agency
9. Payee Identification Number 10. PDT 11. PCC 12. Requisition Number 13. Document Amount
14. Payee Name/Address 15. GSC Order Number 17. AGENCY USE
16. Lease Number
18. Ref Doc SFX M TC Index PCA AY COBJ AOBJ AMOUNT R
SFX APPN Fund NACUBO Sub-Fund Grant Number Grant Year/Phase Project Number Project Phase Contract Number Multipurpose Code
001 Invoice Number Description AGENCY USE (Month of Service,R/D,PAC,and APD No must be completed on all FPS 4116-X) MM/YY (Mo. of Ser.) REG/DIV PAC APD No.
SFX APPN Fund NACUBO Sub-Fund Grant Number Grant Year/Phase Project Number Project Phase Contract Number Multipurpose Code
002 Invoice Number Description AGENCY USE (Month of Service,R/D,PAC,and APD No must be completed on all FPS 4116-X)
SFX APPN Fund NACUBO Sub-Fund Grant Number Grant Year/Phase Project Number Project Phase Contract Number Multipurpose Code
003 Invoice Number Description AGENCY USE (Month of Service,R/D,PAC,and APD No must be completed on all FPS 4116-X)
19. SER/DEL DATE 20. DESCRIPTION OF GOODS OR SERVICES 21. QUANTITY 22. UNIT PRICE 23. AMOUNT
Provider Certification Phone (Area Code and Number) GSC Approval X X
24. Contact Name Phone (Area Code and Number) 25. Entered By
26. I approved this voucher for payment. The above goods or services correspond in every particular with the contract under which they were purchased. The invoice for the goods or services is correct. This payment complies with the General Appropriations Act.
Subrecipient Certification Signatory: The following applies to state and federal funds: "By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)."
APPROVED:
Sign Here
Mail Code Phone (Area Code and Number) Date
APPROVED:
Sign Here
Mail Code Phone (Area Code and Number) Date
File details come from the government source that posted it. Updated .