Standard Form 1034A
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:

DIFFERENCES

PROVISIONAL

COMPLETE

PARTIAL

FINAL

Amount verified; correct for

PROGRESS

(Signature or initials)

ADVANCE

MEMORANDUM

ACCOUNTING CLASSIFICATION

PAID BY

 Previous edition usuable.

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.