PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP64-00360R000600020096-9
• Release Decision: RIPPUB
• Original Classification: K
• Document Page Count: 2
• Document Creation Date: December 12, 2016
• Document Release Date: May 14, 2002
• Sequence Number: 96
• Publication Date: May 23, 1958
• Content Type: FORM

Standard Form No. 1084-Revised D. O. Vou. No_ ____________________-___--__--
Ibrm prescribed b Approved ce1QAWM% P
Comptroller General, ~J. S. !A
.1 (Gen. Reg No. 61, Supp SERVICES OTHER THA P &&O"R00060002009
Bu. Vou. No- ----- ,[
U. S- ----- LT__ 1T_ iS LE --- ----------------------------------------------------------------------------------
(Department, bureau, or establishment)
Voucher prepared at --------------------------------------------------------------------------------------------------------
(Give place and date)
THE UNITED STATES, Dr., Payee's Account No. ________________
To -----------------------------------------------Q
(Payee) COPY ( OF '-
No. and Date of
Order
PAYMENT:
Complete ^
Partial ^
Final ^
Date of Delivery
or Service
ARTICLES OR SERVICES
(Enter description item number of contract or Federal supply
schedule, and other information deemed necessary)
Discount Terms
Shipped from to Weight Government B/L No. I Total
(Payee must NOT use this space)
I certify that the above bill is correct and just and that payment has not been received.
/ STATOTHR
Date ---5/23 /58 *P .'-
l0~6o '
---------------
---------------
---------------
Amount verified; correc .for ________ .. p /d 16
(Signature or initials) AtIt ----------------------------------
Date Req. No. Date Invoice Rec'd.
Pursuant to authority vested in me, I certify that this account is correct and proper for payment.
SIGN
ORIGINAL
ONLY
--- ------- ----------
----------------------- (Authorized OertifyIng Officer)
Title ----------------------- ----------------------------------- Date --------------------------------------------------------------------------
THE REVERSE OF THIS FORM MUST BE EXECUTED WHEN PURCHASES ARE MADE OR SERVICES SECURED WITHOUT WRITTEN AGREEMENT IN ANY FORM
ACCOUNTING CLASSIFICATION (Appropriation Symbol must be shown; other classification optional)
Check No. dated 19 - for $ _________________________________ {on Treasurer of the United States in favor of
.
Paid by
Cash, $------------------------? on ------------------------------------ 1 19 ------ Payee -------------------------------- payee ------ named above -----------------------
(31rn .10-1 only)
I the company rotate Ll~Q}Q}l0 dz? ~Px~p
Jddllaan m e r t o T o t c.
C
"
ompany
John Doo
t If the ability to cer fy and authority to approve are combined in one person, one signature only Is nec-
essary; otherwise the approving officer will sign on the line below "Approved for $___________________", and
over his official title.
Per ----------------------------------------------------------------
4-00360 R000600020096-9
Title -------------------------------------------------------
16-22000-e
 Approved For Release 2002/06/10 : CIA-RDP64-0036OR000600020096-9
Approved For Release 2002/06/10 : CIA-RDP64-0036OR000600020096-9