53.301-1034 Standard Form 1034

F




Standard Form 1034
Revised October 1987
Department of the Treasury
1 TFM 4-2000

PUBLIC VOUCHER FOR PURCHASES AND
SERVICES OTHER THAN PERSONAL

VOUCHER NO.

U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION

DATE VOUCHER PREPARED

SCHEDULE NO.

 

CONTRACT NUMBER AND DATE

PAID BY

 

REQUISITION NUMBER AND DATE

 

 

 

 

 

 

 

 

 

 

 

PAYEE'S
NAME
AND
ADDRESS

 

 

 

 

 

DATE INVOICE RECEIVED

 

 

 

 

 

 

DISCOUNT TERMS

 

 

PAYEE'S ACCOUNT NUMBER

SHIPPED FORM

TO

 

WEIGHT

GOVERNMENT 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)

QUANTITY

UNIT PRICE

AMOUNT

 

 

 

 

COST

PER

(1)

 

 

 







 

 

 

 

(Use continuation sheet(s) if necessary)

(Payee must NOT use the space below)

 

TOTAL

 

PAYMENT:

APPROVED FOR
                     = $

EXCHANGE RATE
                = $1.00

DIFFERENCES

 

 

PROVISIONAL

 

 

 

 

COMPLETE

BY 2

 

 

 

PARTIAL

 

 

 

 

FINAL

 

 

Amount verified; correct for

 

PROGRESS

TITLE

 

(Signature or initials)

 

ADVANCE

 

 

 

 

Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment.

____________
(Date)

_______________________________________
(Authorized Certifying Officer) 2

_______________________________________
(Title)

ACCOUNTING CLASSIFICATION

 


PAID BY

CHECK NUMBER

ON ACCOUNT OF U.S. TREASURY

CHECK NUMBER

ON (Name of bank)

CASH
$

DATE

PAYEE 3

 

1 When stated in foreign currency, insert name of currency.

2 If the ability to certify and authority to approve are comined in one person, one signature only is necessary; otherwise the approving officer will sign in the space provided, over his official title.

PER

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 sign, must appear. For example: " John Doe Company, per John

TITLE

Previous edition usuable.

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.