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Fill and Sign the Standard Form 1034 Hhsgov

Fill and Sign the Standard Form 1034 Hhsgov

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Standard Form 1034 Revised October 1987 Department of the Treasury 1 TFM 4-2000 1034-121PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL VOUCHER NO. SCHEDULE NO. DATE VOUCHER PREPARED U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION CONTRACT NUMBER AND DATE REQUISITION NUMBER AND DATE PAID BY DATE INVOICE RECEIVED DISCOUNT TERMS PAYEE'S ACCOUNT NUMBER PAYEE'S NAME AND ADDRESS SHIPPED FROM TO WEIGHTGOVERNMENT B/L NUMBER NUMBER AND DATE OF ORDER DATE OF DELIVERY OR SERVICE ARTICLES OR SERVICES (Enter description, item number of contract or Federal supply schedule, and other information deemed necessary) QUAN- TITY UNIT PRICE COST PER AMOUNT 2 (Use continuation sheet(s) if necessary) (Payee must NOT use the space below) TOTAL PAYMENT PROVISIONAL COMPLETE FINAL PARTIAL PROGRESS ADVANCE APPROVED FOR =$ EXCHANGE RATE =$1.00DIFFERENCES () 1 BY Amount verified; correct for (Signature or initials) TITLE Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment. (Date) (Authorized Certifying Officer) (Title) 1 ACCOUNTING CLASSIFICATION PAID BY CHECK NUMBER ON ACCOUNT OF U.S. TREASURY CHECK NUMBER ON (Name of bank) PAYEE CASH DATE $ TITLE PER When stated in foreign currency, insert name of currency. 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. When a voucher is receipted in the name of a company or corporation, the name of the person w riting the company or corporate name, as well as the capacity in which he signs, must appear. For example: "John Doe Compan y, per John Smith, Secretary", or "Treasurer", as the case may be. Previous edition usable 3 PRIVACY ACT STATEMENT 3 2 The information requested on this form is required under the pro visions of 31 U.S.C. 82b and 82c, for the purpose of disbursing Federal m oney. 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. NSN 7540-00-900-2234 SF 1034 (E) (CDC Adobe Acrobat 4.0 Electronic Version 11/99) 2 OFFICE OF THE U.S. ATTORNEY CENTRAL DISTRICT OF CALIFORNIA 312 N. SPRING STREET LOS ANGELES, CA 90012 // // // // // // $0.00 // // $0.00 // // $0.00 // // $0.00 // // $0.00 // // $0.00 // // $0.00 // // $0.00 // // $0.00 $0.00 // //

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