State Form 12537 - Report Of Partial Delivery
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Requisition number
Date of requisition
This page number
Total number of pages
REPORT OF PARTIAL DELIVERY
F
State Form 12537 (R6 / 1-08)
Purchase Order number
Approved by Auditor of State, 2008
Approved by State Board of Accounts, 2008
Purchase Order date
Required delivery date
RECYCLED PAPER
Fund
Account
Budget Reference
I.D.O.A. identification number
______
This is the
partial delivery reported on this order.
Program
Department
Federal I.D. number
Business Unit
Name & address
Name of requesting Business Unit / Approp. name
of vendor
Reporting Code (1099)
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
RECEIVED
Item
No.
Please pay this amount:
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
I certify that the vendor has performed in accordance with the terms and
the date indicated. All commodities appeared to conform to specifications
contract obligations pertaining to the Purchase Order, and I hereby athorize
and showed no patent defects, except as otherwise noted.
and approve payment of appropriate claims.
Signature of Receiver
Typed / printed name
Authorized Signature for Business Unit
Typed / printed name
Date signed
Date signed
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Parent category: Financial