Standart Form 1034 - Public Voucher For Purchases And Services Other Than Personal - Department Of The Treasury

VOUCHER NO.

Standard Form 1034

PUBLIC V OUCHER FOR PURCHASES AND

Revised October 1987

Department of the Treasury

SERVICES OTHER THAN PERSONAL

1 TFM 4-2000

Invoice Number

1034-122

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

DATE VOUCHER PREPARED

SCHEDULE NO.

Date Prepared

Project ID Number

CONTRACT NUMBER AND DATE

PAID BY

Agency for Healthcare Research and Quality

Division of Contracts Management

Contract Number / Task Order Number

5600 Fishers Lane, Mail Stop: 06N34B

REQUISITION NUMBER AND DATE

Rockville, MD 20857

Organization Name (legal business name and/or d/b/a)

Organization Street Address, Suite No. Mail Stop

City, State Zip-code +4

DATE INVOICE RECEIVED

PAYEE’S

NAME

XXXXXXXXX

DUNS

:

DISCOUNT TERMS

AND

TIN:

XX-XXX-XXXX

ADDRESS

If there are questions concerning this invoice please contact:

PAYEE’S ACCOUNT NUMBER

First and Last Name, Title

Phone # and

Email Address

GOVERNMENT B/L NUMBER

SHIPPED FROM

TO

WEIGHT

DATE OF

UNIT PRICE

AMOUNT

NUMBER

ARTICLES OR SERVICES

DELIVERY

QTY.

AND DATE

(Enter description, item number of contract or Federal supply

OR

1

COST

PER

(

)

OF ORDER

schedule, and other information deemed necessary)

SERVICE

“I certify that all payments requested are for appropriate purposes

From:

and in accordance with the terms and conditions of the contract /

Beginning

task order.” See the attached detailed breakdown of cost / price.

To:

Ending

CONTRACTOR SIGNATURE

Name:

Title:

(Use continuation sheets if

(Payee must NOT use the space below)

TOTAL

$X,XXX.XX

PAYMENT:

APPROVED FOR

EXCHANGE RATE

DIFFERENCES

PROVISIONAL

=$

USD

=$1.00

2

COMPLETE

BY

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.

2

(Date)

(Authorized Certifying Officer)

(Title)

ACCOUNTING CLASSIFICATION

CHECK NUMBER

ON ACCOUNT OF U.S. TREASURY

CHECK NUMBER

ON (Name of bank)

3

CASH

DATE

PAYEE

$

1

PER

When stated in foreign currently, 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

TITLE

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.

Previous edition usable

NSN 7650-00-634-4206

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.