Att_1_-_DD_Form_1155_(Example).pdf

ORDER FOR SUPPLIES OR SERVICES

1. CONTRACT/PURCH ORDER/AGREEMENT NO. 2. DELIVERY ORDER/CALL NO. 4. REQUISITION/PURCH REQUEST NO.3. DATE OF ORDER/CALL

(YYYYMMMDD)

5. PRIORITY

6. ISSUED BY 7. ADMINISTERED BY If other than 6 8. DELIVERY FOB

9. CONTRACTOR

NAME

AND

ADDRESS

10. DELIVER TO FOB POINT BY (Date)

(YYYYMMMDD)

12. DISCOUNT TERMS

13. MAIL INVOICES TO THE ADDRESS IN BLOCK

(See Schedule if other)

11. X IF BUSINESS IS

14. SHIP TO 15. PAYMENT WILL BE MADE BY MARK ALL

PACKAGES AND

PAPERS WITH

IDENTIFICATION

NUMBERS IN

BLOCKS 1 AND 2.

16.

TYPE

OF

ORDER ACCEPTANCE.

(YYYYMMMDD)

17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE

18. ITEM NO. 19. SCHEDULE OF SUPPLIES/SERVICES

20. QUANTITY

ORDERED/

ACCEPTED*

21.

UNIT

22. UNIT PRICE 23. AMOUNT

* If quantity accepted by the Government is same as quantity ordered, indicate by X.

If different, enter actual quantity accepted below quantity ordered and encircle.

24. UNITED STATES OF AMERICA 25. TOTAL

26.

DIFFERENCES

27a. QUANTITY IN COLUMN 20 HAS BEEN

INSPECTED RECEIVED

ACCEPTED, AND CONFORMS TO

THE CONTRACT EXCEPT AS NOTED:

YYYYMMMDD

28. SHIP. NO. 29. D.O. VOUCHER NO. 30. INITIALS

32. PAID BY 33. AMOUNT VERIFIED CORRECT FOR

36. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT.

YYYYMMMDD

DD FORM 1155, DEC 2001

37. RECEIVED

AT

38. RECEIVED BY Print 39. DATE RECEIVED

YYYYMMMDD

31. PAYMENT

40. TOTAL CON-

TAINERS

41. S/R ACCOUNT NUMBER 42. S/R VOUCHER NO.

34. CHECK NUMBER

35. BILL OF LADING NO.

X

XYZ Company

X

XXXXXXXXXXXXXXX

ATTACHMENT 1

SECTION B

12 XX