TAX EXEMPTION FORMS ACCOUNTABILITY RECORD

To be used for convenience of the issuing agency for maintaining a control record tax exemption forms issued.

TAX EXEMPTION
FORMS IN THIS
BOOK NUMBERED

►

FORM

THROUGH

TAX EXEMPTION FORMS RETURNED UNUSED
FOR REISSUE

►

FORM

THROUGH

ISSUED TO

REISSUED TO

NAME

NAME

TITLE

TITLE

OFFICE DESIGNATION

OFFICE DESIGNATION

ISSUING
OFFICER

ISSUING
OFFICER

FORM

Mark "X" in appropriate column to indicate type of tax ►

TAX
EXCLUDED
(AMOUNT $)

STATE

LOCAL

TRANSACTION
REFERENCE

NO.

DATE

VENDOR NAME AND ADDRESS

ITEM PURCHASED

VOUCHER NO:

VOUCHER DATE:

PO/Cont. No.:

VOUCHER NO:

VOUCHER DATE:

PO/Cont. No.:

VOUCHER NO:

VOUCHER DATE:

PO/Cont. No.:

VOUCHER NO:

VOUCHER DATE:

PO/Cont. No.:

STANDARED FORM 1094A (REV. 12.69)
Prescribed by GSA-FAR (CFR) 53.229