PUBLIC VOUCHER FOR PURCHASES AND
SERVICES OTHER THAN PERSONAL
VOUCHER NO.
U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION DATE VOUCHER PREPARED
CONTRACT NUMBER AND DATE
REQUISITION NUMBER AND DATE
SCHEDULE NO.
PAID BY
DATE INVOICE RECEIVED
DISCOUNT TERMS
PAYEE'S ACCOUNT NUMBER
GOVERNMENT B/L NUMBER
SHIPPED FROM TO WEIGHT
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
(Use continuation sheet(s) if necessary)
(Payee must NOT use the space below)
TOTAL
DIFFERENCES
PAYMENT:
APPROVED FOR EXCHANGE RATE
BY
TITLE
Amount verified; correct for payment
(Signature or initials)
=$
=$1.00
Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment.
(Date)
ACCOUNTING CLASSIFICATION
P
A
I
D
CHECK NUMBER
CASH
ON ACCOUNT OF U.S. TREASURY
DATE
$
CHECK NUMBER
PAYEE
ON (Name of bank)
PER
TITLE
NSN 7540-00-900-2234
Standard Form 1034
Revised October 1987
Department of the Treasury
1 TFM 4-2000
PAYEE'S
NAME
AND
ADDRESS
NUMBER AND DATE
OF ORDER
(1)
PROVISIONAL
COMPLETE
PARTIAL
FINAL
PROGRESS
ADVANCE
2
(Title)
(Authorized Certifying Officer)
3
Previous edition usable
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.
1. When stated in foreign currency, insert name of currency.
2. 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.
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 signs, must appear. For example: "John Doe Company, per John Smith, Secretary", or
"Treasurer", as the case may be.
B
Y
2
