Attachment_J.5_-_SF-1034.pdf

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 # of contract or Federal supply schedule, and other information deemed necessary)

QUAN-

TITY

UNIT PRICE AMOUNT(1)

COST PER

$0.00

(Use continuation sheet(s) if necessary) (Payee must NOT use the space below) TOTAL $0.00

PAYMENT:

APPROVED FOR

EXCHANGE RATE

DIFFERENCES

P

A

I

D

B

Y

PROVISIONAL BY:

AMOUNT VERIFIED;

CORRECT FOR

PARTIAL

FINAL

PROGRESS TITLE:

(SIGNATURE OR INITIALS)

ADVANCE

PURSUANT TO AUTHORITY VESTED IN ME, I CERTIFY THIS VOUCHER IS CORRECT AND PROPER FOR PAYMENT.

(DATE) (AUTHORIZED CERTIFYING OFFICER) (TITLE)

ACCOUNTING CLASSIFICATION

DOC NO EARMARK CURRCODE CURRENCY FUNDING

CHECK NUMBER

ON ACCOUNT OF U.S.

TREASURY

CHECK NUMBER

ON (Name of Bank)

CASH

DATE

PAYEE

1When stated in foreign currency, insert name of currency.

2If 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.

3When 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 7540-00-900-2234

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 1987Department of the Treasury

Revised October 1987 1 TFM 4-2000 1034-121