State Form 12537 - Report Of Partial Delivery
ADVERTISEMENT
1O
Requisition number
This page number
Total number of pages
Date of requisition
REPORT OF PARTIAL DELIVERY
F
State Form 12537 (R7 / 9-09)
Purchase Order number
Approved by Auditor of State, 2009
Approved by State Board of Accounts, 2009
Purchase Order date
Required delivery date
Fund
Account
Bud Ref
Project
I.D.O.A. identification number
This is the
______
partial delivery reported on this order.
Business Unit
Program
Department
Activity
Federal I.D. number
Name & address
Name of requesting Business Unit / Approp. name
of vendor
INSTRUCTIONS:
Delivered to:
Use this form only for reporting partial deliveries on a Purchase Order. Use the
receiving room copy (part 4) of the Purchase Order for reporting the final
delivery on the order. Forward this report without delay to:
AUDITOR OF STATE
200 W WASHINGTON ST RM 144
INDIANAPOLIS, IN 46204
This document authorizes the Auditor to pay the claim
NOTICE: No price corrections will be permitted after issuance of this Purchase Order.
F.O.B. DESTINATION unless otherwise stated below
Contract
QUANTITY
Line
UNIT
ARTICLE and DESCRIPTION
UNIT PRICE
AMOUNT
Item
RECEIVED
No.
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Please pay this amount:
$0.00
REQUESTING BUSINESS UNIT'S CERTIFICATION OF RECEIPT AND COMPLIANCE
Confirmation of Receipt
Approval for Payment
I certify that the items listed above were received and checked by me on the date indicated.
I certify that the vendor has performed in accordance with the terms and contract obligations pertaining to the Purchase
All commodities appeared to conform to specifications and showed no patent defects, except
Order, and hereby authorize and approve payment of appropriate claims.
as otherwise noted.
Signature of Receiver
Typed / printed name
Authorized Signature for Business Unit
Typed / printed name
Date signed
Date signed
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal