PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP64-00360R000600020026-6
• Release Decision: RIPPUB
• Original Classification: K
• Document Page Count: 2
• Document Creation Date: December 12, 2016
• Document Release Date: May 14, 2002
• Sequence Number: 26
• Publication Date: July 18, 1958
• Content Type: FORM

Y
9ta.. ,1~art1 Form No. 1084-Revised
Form proscribed by
Comptroller General, . S. ed
September 7 1950 Approv en.
No. ? (G(Am nded February 20, 952)1)
OR00060002002~1642
Bu. Vou. No- ---------------------------------
U. S. ------- fOSS-. ILBUBSt -------------------------------------------------------------------------------------
(Department, bureau, or establishment)
Voucher prepared at --------------------------------------------------------------------------------------------------------
(Give place and date)
THE UNITED STATES, Dr., Payee's Account No.._______________
To ----------------------------------------------------------------------- ------------------------------------------------------------
(Payee)
----------------------------------------------------------------------------------------------------------------------------------------
(Address) (City) (State)
ARTICLES OR SERVICES
UNIT PRICE
AMOUNT
t
f
N
d D
te
f Deliver
D
item number of contract or Federal supply
(Enter description
e o
o. an
a
Order
y
o
a
or Service
t
schedule, and other information deemed necessary)
QUANTITY
Cost
Per
Dollars
Cts.
Discount Terms
Cost
(14i.,1ll-2
.08
PAYMENT:
Complete ^
Partial F-1
Final ^
Use continuation sheet(s) if necessary
Shipped from to Weight Government B/L No.
Total
(44,142
08
(Payee must NOT use this space)
I certify that the above bill is correct and just and that payment has not been received.
Differences ---------------------------------
--------------- -----
STATOTH R (Sign original only)
*
Date --- 7/
- -------------------------------------------------------------
ete not ropoired when like eertifloete 1. med. by my.. on att.ehed bl or bill.)
-----------------------------------------------
Amount verified;
correc for
------------------------
t L
-------------- ----
.
Per Title -----?------------ ---.------
-----------
(Signature
or initials)
-----------
Contract No. Date Req. No.
Contract
Invoice Recd.
Pursuant to authority vested in me, I certify that this account is correct and proper for payment,
t Approved for $ --------------------------------- t ------------------------------------------------------------------------------
SIGN (Authorized Certifying Officer)
By -------------------- ------------------------- ORIGINAL Title --------------------------------------------------------------------------
ONLY
Title ---------------------------------------------------------- Date --------------------------------------------------------------------------
THE REVERSE OF THIS FORM MUST BE EXECUTED WHEN PURCHASES ARE MADE OR SERVICES SECURED WITHOUT WRITTEN AGREEMENT IN ANY FORM
Check No- ________________________ dated ------------------------------ 19------ for $-------------------------------------- fork Treasurer of the United States in favor of
Paid by payee named above.
{ Cash, $------------------------r on --- --------------------------------- 19 ------ Payee ------------------------------------------------------------------------
(Sh a orialnel only)
' When a voucher is signed or receipted in the name of a company or corporation, the name of the person a __ _______________
writing the company or corporate n&ft e~e1 amen
"John Doe Company, per John Sni`2i fl; B2e1~5C6f'q dr "Trda3~`Ciid`e~ls~iy~A ~'~-TAU-803~bFf000600020026-6
t If the ability to certify and authority to approve are combined In one person, one signature only is noe- Title _____________________________
essary; otherwise the approving officer will sign on the line below "Approved for $___________________", and
over his official title. 10-22000-e
 STATOTHR
Approved For Release 2002/06/10 : CIA-RDP64-00360R000600020026-6
Approved For Release 2002/06/10 : CIA-RDP64-00360R000600020026-6