Fill and Sign the Clico Medical Claim Form

GPO Fom 2511 (IR 1-89) P. 57870-3 Print PRINT ORDER Clear You are hereby authorized to manufacture and ship the following described product in accordance with the purchase order and specifications indicated. DEPARTMENT REQ. NO DATE PURCHASE ORDER NO. / CONTRACTOR PRINT ORDER NO. / JACKET NO. SHIP/DEL DATE / TITLE OBJECT CLASS PROOFS STATE CODE / DAYS GOV'T WILL HOLD DATE DUE TO GOV'T RETURN DATE TO CONTR. PROGRAM NO. APPROPRIATION CHARGEABLE BILLING ADDRESS CODE (BAC) QUANTITY COMPOSITION Phototype Cold Type SETS CONTR'S CODE QUALITY LEVEL TRIM SIZE Galley Page Hot Metal Blues MATERIAL FURNISHED TO CONTRACTOR Halftones Manuscript Camera Copy Line Illus. TEXT STOCK COVER STOCK FOUR COLOR PROCESS PRNTG. Cover 1 2 3 4 Text COLOR OF INK Cover Text 1 ULC Sew Trim 4 Sides Shrink Film Wrap units of NO. OF TEXT PAGES (Including Blanks) COVER PRINTS 1 2 3 4 Drill BINDING FOLD-IN STOCK FOLD-lNS/FORMS Face & Back Face Only NEGATIVES (No. Required) STRIP-INS Band units of Saddle Other Binders Negatives Side Perfect Perf. on Fold Other round holes " in diameter on inches c. to c. edge of sheet sheets/sets each. Pad on the Pads of Adhesive Strip side inches from " side. Chipboard required. Center of holes Pack per shipping container. RETURN NEGS TO GPO FOR STORAGE DISTRIBUTION NO Pallets required. YES RETURN ORIG. AND/OR NEGS. TO: Departmental Authority (Signature and Title) DATE SENT TO CONTRACTOR Purchase Obligation / / CONTRACTOR TO COMPLETE BOTTOM PORTION AND MAIL ENTIRE FORM TO: COMPTROLLER-FME, FINANCIAL MANAGEMENT SERVICE, U.S. GOVERNMENT PRINTING OFFICE, WASHINGTON, D.C. 20401 Contractor Invoice No. Date of Delivery/Shipment Date Prepared / / / / Discount Terms UNIT PRICE ARTICLES OR SERVICES QUANTITY COST IF ADDITIONAL SPACE IS REQUIRED, USE STD. FORM 1034, 1035, OR ATTACH YOUR INVOICE. AMOUNT PER TOTAL I CERTIFY THAT THE MATERIAL, GOODS, OR SERVICES HAVE BEEN DELIVERED/SHIPPED ON THE DATE INDICATED ABOVE AND THAT PAYMENT OR CREDIT HAS NOT BEEN RECEIVED. The penalty for making false statements to the Government is prescribed in 18 USC 1001. PART 1 - CONTRACTOR (Signature of person authorized to sign) GPO Fom 2511 (IR 1-89) P. 57870-3 PRINT ORDER You are hereby authorized to manufacture and ship the following described product in accordance with the purchase order and specifications indicated. DEPARTMENT REQ. NO DATE PURCHASE ORDER NO. / CONTRACTOR PRINT ORDER NO. / JACKET NO. SHIP/DEL DATE / TITLE OBJECT CLASS PROOFS STATE CODE / DAYS GOV'T WILL HOLD DATE DUE TO GOV'T RETURN DATE TO CONTR. PROGRAM NO. APPROPRIATION CHARGEABLE BILLING ADDRESS CODE (BAC) QUANTITY COMPOSITION Phototype Cold Type SETS CONTR'S CODE QUALITY LEVEL TRIM SIZE Galley Page Hot Metal Blues MATERIAL FURNISHED TO CONTRACTOR Halftones Manuscript Camera Copy Line Illus. TEXT STOCK COVER STOCK FOUR COLOR PROCESS PRNTG. Cover 1 2 3 4 Text COLOR OF INK Cover Text 1 ULC Sew Trim 4 Sides Shrink Film Wrap units of NO. OF TEXT PAGES (Including Blanks) COVER PRINTS 1 2 3 4 Drill BINDING FOLD-IN STOCK FOLD-lNS/FORMS Face & Back Face Only NEGATIVES (No. Required) STRIP-INS Band units of Saddle Other Binders Negatives Side Perfect Perf. on Fold Other round holes side inches c. to c. inches from edge of sheet sheets/sets each. Pad on the Pads of Adhesive Strip " in diameter on " side. Chipboard required. Center of holes Pack per shipping container. RETURN NEGS TO GPO FOR STORAGE DISTRIBUTION NO Pallets required. YES RETURN ORIG. AND/OR NEGS. TO: Departmental Authority (Signature and Title) DATE SENT TO CONTRACTOR Purchase Obligation / / CONTRACTOR TO COMPLETE BOTTOM PORTION AND MAIL ENTIRE FORM TO: COMPTROLLER-FME, FINANCIAL MANAGEMENT SERVICE, U.S. GOVERNMENT PRINTING OFFICE, WASHINGTON, D.C. 20401 Contractor Invoice No. Date of Delivery/Shipment Date Prepared / / / / Discount Terms UNIT PRICE ARTICLES OR SERVICES QUANTITY COST AMOUNT PER IF ADDITIONAL SPACE IS REQUIRED, USE STD. FORM 1034, 1035, OR ATTACH YOUR INVOICE. TOTAL I CERTIFY THAT THE MATERIAL, GOODS, OR SERVICES HAVE BEEN DELIVERED/SHIPPED ON THE DATE INDICATED ABOVE AND THAT PAYMENT OR CREDIT HAS NOT BEEN RECEIVED. The penalty for making false statements to the Government is prescribed in 18 USC 1001. PART 2 - CONTRACTOR - (BILLING COPY) (Signature of person authorized to sign) GPO Fom 2511 (IR 1-89) P. 57870-3 PRINT ORDER You are hereby authorized to manufacture and ship the following described product in accordance with the purchase order and specifications indicated. DEPARTMENT REQ. NO DATE PURCHASE ORDER NO. / CONTRACTOR PRINT ORDER NO. / JACKET NO. SHIP/DEL DATE / TITLE OBJECT CLASS PROOFS STATE CODE / DAYS GOV'T WILL HOLD DATE DUE TO GOV'T RETURN DATE TO CONTR. PROGRAM NO. APPROPRIATION CHARGEABLE BILLING ADDRESS CODE (BAC) QUANTITY COMPOSITION Phototype Cold Type SETS CONTR'S CODE QUALITY LEVEL TRIM SIZE Galley Page Hot Metal Blues MATERIAL FURNISHED TO CONTRACTOR Halftones Manuscript Camera Copy Line Illus. TEXT STOCK COVER STOCK FOUR COLOR PROCESS PRNTG. Cover 1 2 3 4 Text COLOR OF INK Cover Text 1 ULC Sew Trim 4 Sides Shrink Film Wrap units of NO. OF TEXT PAGES (Including Blanks) COVER PRINTS 1 2 3 4 Drill BINDING FOLD-IN STOCK FOLD-lNS/FORMS Face & Back Face Only NEGATIVES (No. Required) STRIP-INS Band units of Saddle Other Binders Negatives Side Perfect Perf. on Fold Other round holes side inches c. to c. inches from edge of sheet sheets/sets each. Pad on the Pads of Adhesive Strip " in diameter on " side. Chipboard required. Center of holes Pack per shipping container. RETURN NEGS TO GPO FOR STORAGE DISTRIBUTION NO Pallets required. YES RETURN ORIG. AND/OR NEGS. TO: Departmental Authority (Signature and Title) DATE SENT TO CONTRACTOR Purchase Obligation / / CONTRACTOR TO COMPLETE BOTTOM PORTION AND MAIL ENTIRE FORM TO: COMPTROLLER-FME, FINANCIAL MANAGEMENT SERVICE, U.S. GOVERNMENT PRINTING OFFICE, WASHINGTON, D.C. 20401 Contractor Invoice No. Date of Delivery/Shipment Date Prepared / / / / Discount Terms UNIT PRICE ARTICLES OR SERVICES QUANTITY COST AMOUNT PER IF ADDITIONAL SPACE IS REQUIRED, USE STD. FORM 1034, 1035, OR ATTACH YOUR INVOICE. TOTAL I CERTIFY THAT THE MATERIAL, GOODS, OR SERVICES HAVE BEEN DELIVERED/SHIPPED ON THE DATE INDICATED ABOVE AND THAT PAYMENT OR CREDIT HAS NOT BEEN RECEIVED. The penalty for making false statements to the Government is prescribed in 18 USC 1001. PART 3 - GPO FILE COPY (Signature of person authorized to sign) GPO Fom 2511 (IR 1-89) P. 57870-3 PRINT ORDER You are hereby authorized to manufacture and ship the following described product in accordance with the purchase order and specifications indicated. DEPARTMENT REQ. NO DATE PURCHASE ORDER NO. / CONTRACTOR PRINT ORDER NO. / JACKET NO. SHIP/DEL DATE / TITLE OBJECT CLASS PROOFS STATE CODE / DAYS GOV'T WILL HOLD DATE DUE TO GOV'T RETURN DATE TO CONTR. PROGRAM NO. APPROPRIATION CHARGEABLE BILLING ADDRESS CODE (BAC) QUANTITY COMPOSITION Phototype Cold Type SETS CONTR'S CODE QUALITY LEVEL TRIM SIZE Galley Page Hot Metal Blues MATERIAL FURNISHED TO CONTRACTOR Halftones Manuscript Camera Copy Line Illus. TEXT STOCK COVER STOCK FOUR COLOR PROCESS PRNTG. Cover 1 2 3 4 Text COLOR OF INK Cover Text 1 ULC Sew Trim 4 Sides Shrink Film Wrap units of NO. OF TEXT PAGES (Including Blanks) COVER PRINTS 1 2 3 4 Drill BINDING FOLD-IN STOCK FOLD-lNS/FORMS Face & Back Face Only NEGATIVES (No. Required) STRIP-INS Band units of Saddle Other Binders Negatives Side Perfect Perf. on Fold Other round holes side inches c. to c. inches from edge of sheet sheets/sets each. Pad on the Pads of Adhesive Strip " in diameter on " side. Chipboard required. Center of holes Pack per shipping container. RETURN NEGS TO GPO FOR STORAGE DISTRIBUTION NO Pallets required. YES RETURN ORIG. AND/OR NEGS. TO: Departmental Authority (Signature and Title) DATE SENT TO CONTRACTOR Purchase Obligation / / CONTRACTOR TO COMPLETE BOTTOM PORTION AND MAIL ENTIRE FORM TO: COMPTROLLER-FME, FINANCIAL MANAGEMENT SERVICE, U.S. GOVERNMENT PRINTING OFFICE, WASHINGTON, D.C. 20401 Contractor Invoice No. Date of Delivery/Shipment Date Prepared / / / / Discount Terms UNIT PRICE ARTICLES OR SERVICES QUANTITY COST AMOUNT PER IF ADDITIONAL SPACE IS REQUIRED, USE STD. FORM 1034, 1035, OR ATTACH YOUR INVOICE. TOTAL I CERTIFY THAT THE MATERIAL, GOODS, OR SERVICES HAVE BEEN DELIVERED/SHIPPED ON THE DATE INDICATED ABOVE AND THAT PAYMENT OR CREDIT HAS NOT BEEN RECEIVED. The penalty for making false statements to the Government is prescribed in 18 USC 1001. PART 4 GPO - FINANCE (Signature of person authorized to sign) GPO Fom 2511 (IR 1-89) P. 57870-3 PRINT ORDER You are hereby authorized to manufacture and ship the following described product in accordance with the purchase order and specifications indicated. DEPARTMENT REQ. NO DATE PURCHASE ORDER NO. / CONTRACTOR PRINT ORDER NO. / JACKET NO. SHIP/DEL DATE / TITLE OBJECT CLASS PROOFS STATE CODE / DAYS GOV'T WILL HOLD DATE DUE TO GOV'T RETURN DATE TO CONTR. PROGRAM NO. APPROPRIATION CHARGEABLE BILLING ADDRESS CODE (BAC) QUANTITY COMPOSITION Phototype Cold Type SETS CONTR'S CODE QUALITY LEVEL TRIM SIZE Galley Page Hot Metal Blues MATERIAL FURNISHED TO CONTRACTOR Halftones Manuscript Camera Copy Line Illus. TEXT STOCK COVER STOCK FOUR COLOR PROCESS PRNTG. Cover 1 2 3 4 Text COLOR OF INK Cover Text 1 ULC Sew Trim 4 Sides Shrink Film Wrap units of NO. OF TEXT PAGES (Including Blanks) COVER PRINTS 1 2 3 4 Drill BINDING FOLD-IN STOCK FOLD-lNS/FORMS Face & Back Face Only NEGATIVES (No. Required) STRIP-INS Band units of Saddle Other Binders Negatives Side Perfect Perf. on Fold Other round holes side inches c. to c. inches from edge of sheet sheets/sets each. Pad on the Pads of Adhesive Strip " in diameter on " side. Chipboard required. Center of holes Pack per shipping container. RETURN NEGS TO GPO FOR STORAGE DISTRIBUTION NO Pallets required. YES RETURN ORIG. AND/OR NEGS. TO: Departmental Authority (Signature and Title) DATE SENT TO CONTRACTOR Purchase Obligation / / CONTRACTOR TO COMPLETE BOTTOM PORTION AND MAIL ENTIRE FORM TO: COMPTROLLER-FME, FINANCIAL MANAGEMENT SERVICE, U.S. GOVERNMENT PRINTING OFFICE, WASHINGTON, D.C. 20401 Contractor Invoice No. Date of Delivery/Shipment Date Prepared / / / / Discount Terms UNIT PRICE ARTICLES OR SERVICES QUANTITY COST AMOUNT PER IF ADDITIONAL SPACE IS REQUIRED, USE STD. FORM 1034, 1035, OR ATTACH YOUR INVOICE. TOTAL I CERTIFY THAT THE MATERIAL, GOODS, OR SERVICES HAVE BEEN DELIVERED/SHIPPED ON THE DATE INDICATED ABOVE AND THAT PAYMENT OR CREDIT HAS NOT BEEN RECEIVED. The penalty for making false statements to the Government is prescribed in 18 USC 1001. PART 5 - GPO CONTRACT COMPLIANCE (Signature of person authorized to sign) GPO Fom 2511 (IR 1-89) P. 57870-3 PRINT ORDER You are hereby authorized to manufacture and ship the following described product in accordance with the purchase order and specifications indicated. DEPARTMENT REQ. NO DATE PURCHASE ORDER NO. / CONTRACTOR PRINT ORDER NO. / JACKET NO. SHIP/DEL DATE / TITLE OBJECT CLASS PROOFS STATE CODE / DAYS GOV'T WILL HOLD DATE DUE TO GOV'T RETURN DATE TO CONTR. PROGRAM NO. APPROPRIATION CHARGEABLE BILLING ADDRESS CODE (BAC) QUANTITY COMPOSITION Phototype Cold Type SETS CONTR'S CODE QUALITY LEVEL TRIM SIZE Galley Page Hot Metal Blues MATERIAL FURNISHED TO CONTRACTOR Halftones Manuscript Camera Copy Line Illus. TEXT STOCK COVER STOCK FOUR COLOR PROCESS PRNTG. Cover 1 2 3 4 Text COLOR OF INK Cover Text 1 ULC Sew Trim 4 Sides Shrink Film Wrap units of NO. OF TEXT PAGES (Including Blanks) COVER PRINTS 1 2 3 4 Drill BINDING FOLD-IN STOCK FOLD-lNS/FORMS Face & Back Face Only NEGATIVES (No. Required) STRIP-INS Band units of Saddle Other Binders Negatives Side Perfect Perf. on Fold Other round holes " in diameter on inches c. to c. edge of sheet sheets/sets each. Pad on the Pads of Adhesive Strip side inches from " side. Chipboard required. Center of holes Pack per shipping container. RETURN NEGS TO GPO FOR STORAGE DISTRIBUTION NO Pallets required. YES RETURN ORIG. AND/OR NEGS. TO: Departmental Authority (Signature and Title) DATE SENT TO CONTRACTOR Purchase Obligation / / CONTRACTOR TO COMPLETE BOTTOM PORTION AND MAIL ENTIRE FORM TO: COMPTROLLER-FME, FINANCIAL MANAGEMENT SERVICE, U.S. GOVERNMENT PRINTING OFFICE, WASHINGTON, D.C. 20401 Contractor Invoice No. Date of Delivery/Shipment Date Prepared / / / / Discount Terms UNIT PRICE ARTICLES OR SERVICES QUANTITY COST IF ADDITIONAL SPACE IS REQUIRED, USE STD. FORM 1034, 1035, OR ATTACH YOUR INVOICE. AMOUNT PER TOTAL I CERTIFY THAT THE MATERIAL, GOODS, OR SERVICES HAVE BEEN DELIVERED/SHIPPED ON THE DATE INDICATED ABOVE AND THAT PAYMENT OR CREDIT HAS NOT BEEN RECEIVED. The penalty for making false statements to the Government is prescribed in 18 USC 1001. PART 6 - DEPARTMENT (Signature of person authorized to sign) GPO Fom 2511 (IR 1-89) P. 57870-3 PRINT ORDER You are hereby authorized to manufacture and ship the following described product in accordance with the purchase order and specifications indicated. DEPARTMENT REQ. NO DATE PURCHASE ORDER NO. / CONTRACTOR PRINT ORDER NO. / JACKET NO. SHIP/DEL DATE / TITLE OBJECT CLASS PROOFS STATE CODE / DAYS GOV'T WILL HOLD DATE DUE TO GOV'T RETURN DATE TO CONTR. PROGRAM NO. APPROPRIATION CHARGEABLE BILLING ADDRESS CODE (BAC) QUANTITY COMPOSITION Phototype Cold Type SETS CONTR'S CODE QUALITY LEVEL TRIM SIZE Galley Page Hot Metal Blues MATERIAL FURNISHED TO CONTRACTOR Halftones Manuscript Camera Copy Line Illus. TEXT STOCK COVER STOCK FOUR COLOR PROCESS PRNTG. Cover 1 2 3 4 Text COLOR OF INK Cover Text 1 ULC Sew Trim 4 Sides Shrink Film Wrap units of NO. OF TEXT PAGES (Including Blanks) COVER PRINTS 1 2 3 4 Drill BINDING FOLD-IN STOCK FOLD-lNS/FORMS Face & Back Face Only NEGATIVES (No. Required) STRIP-INS Band units of Saddle Other Binders Negatives Side Perfect Perf. on Fold Other round holes " in diameter on inches c. to c. edge of sheet sheets/sets each. Pad on the Pads of Adhesive Strip side inches from " side. Chipboard required. Center of holes Pack per shipping container. RETURN NEGS TO GPO FOR STORAGE DISTRIBUTION NO Pallets required. YES RETURN ORIG. AND/OR NEGS. TO: Departmental Authority (Signature and Title) DATE SENT TO CONTRACTOR Purchase Obligation / / CONTRACTOR TO COMPLETE BOTTOM PORTION AND MAIL ENTIRE FORM TO: COMPTROLLER-FME, FINANCIAL MANAGEMENT SERVICE, U.S. GOVERNMENT PRINTING OFFICE, WASHINGTON, D.C. 20401 Contractor Invoice No. Date of Delivery/Shipment Date Prepared / / / / Discount Terms UNIT PRICE ARTICLES OR SERVICES QUANTITY COST IF ADDITIONAL SPACE IS REQUIRED, USE STD. FORM 1034, 1035, OR ATTACH YOUR INVOICE. AMOUNT PER TOTAL I CERTIFY THAT THE MATERIAL, GOODS, OR SERVICES HAVE BEEN DELIVERED/SHIPPED ON THE DATE INDICATED ABOVE AND THAT PAYMENT OR CREDIT HAS NOT BEEN RECEIVED. The penalty for making false statements to the Government is prescribed in 18 USC 1001. PART 7 - DEPARTMENT (Signature of person authorized to sign)