Fill and Sign the Scope of Work Template Form

Standard Form 1034 Revised October 1967 Department of the Treasury 1 TFM 4-2000 1034-121 VOUCHER NO. PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION (invoice number) DATE VOUCHER PREPARED SCHEDULE NO. Ending date of course (not prior to) Double-check your purchase order for the proper payment office location – your payment voucher must CONTRACT NUMBER AND DATE #3 and #1 on purchase order be sent to this address. PAID BY REQUISITION NUMBER AND DATE #4 on purchase order Name and address as shown on purchase order PAYEE'S NAME AND ADDRESS DATE INVOICE RECEIVED DISCOUNT TERMS PAYEE'S ACCOUNT NUMBER SHIPPED FROM NUMBER AND DATE OF ORDER TO DATE OF DELIVERY OR SERVICE Course Date ARTICLES OR SERVICES (Enter description, item number of contract or Federal supply schedule, and other information deemed necessary) PARTIAL APPROVED FOR =$1.00 ADVANCE COST AMOUNT ( 1 ) PER the $ job: TOTAL DIFFERENCES 2 FINAL PROGRESS UNIT PRICE EXCHANGE RATE =$ BY $ for GOVERNMENT B/L NUMBER (Payee must NOT use the space below) PROVISIONAL COMPLETE QUANTITY Enter the course title of the course you taught and the location of the course. The title is listed on page two of your purchase order. (Use continuation sheet(s) if necessary) PAYMENT: WEIGHT Amount verified; correct for payment TITLE (Signature or initials) Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment. (Date) (Authorized Certifying Officer) ACCOUNTING CLASSIFICATION (Title) NOTE: Invoices will not be accepted before the service has been provided. If your voucher is received prior to the dates of service, it will be returned to you. P A I D B Y CHECK NUMBER ON TREASURER OF THE UNITED STATES CHECK NUMBER CASH $ DATE PAYEE ON (Name of bank) 3 1 When stated in foreign currency, insert name of currency. 2 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. 3 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. FOR 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.