U.S. GOVERNMENT

PURCHASE ORDER-INVOICE-VOUCHER

DATE OF ORDER

ORDER NO.

PRINT NAME AND ADDRESS OF SELLER (Numbers, Street, City, and State)*

P
A
Y
E
E

FURNISH SUPPLIES OR SERVICES TC (Name and address)*

SUPPLIES OR SERVICES

QUANTITY

UNIT PRICE

AMOUNT

AGENCY NAME AND BILLING ADDRESS*

TOTAL

P
A
Y
O
R

DISCOUTN TERMS

………….%................ DAYS

DATE INVOICE RECEIVED

ORDERED BY (Signature and title)

PURPOSE AND ACCOUNTING DATA

PURCHASER – To sign below for over-the counter delivery of items

RECEIVED BY

TITLE

DATE

SELLER – Please read instructions on Copy 2

PAYMENT RECEIVED $............................

PAYMENT REQUESTED $.............................

NO FURTHER INVOICE NEED BE SUBMITTED

SELLER

DATE

BY……………………………………………………………………

(Signature)

Remarks

[ILLEGIBLE]

[ILLEGIBLE]

RECORD OF PURCHASES

ORDER NO

NAME OF CONTRACTOR

SUM OF PURCHASES

REMARKS