PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP64-00360R000600040164-1
• Release Decision: RIPPUB
• Original Classification: K
• Document Page Count: 2
• Document Creation Date: December 9, 2016
• Document Release Date: June 2, 2001
• Sequence Number: 164
• Publication Date: March 2, 1959
• Content Type: FORM

STATI fL
Standard.
Form Form No. 103A-Revised i
Comet ollcr prescribed yb fDVed For RS#
Soptomber lpp Reg. No, b1, fjupp:No. 11) SER K ,
(Gen. ~1
(Amended February 2O, 1082)
FF D. O. Vou. No- -------------------------------
J~ 6 4-1
jOOO4O1
Bu. Vou. No. __________ 2_396______________
U. S. ---C0ST--REIMBUR,9ABLE ----------------------------------------------------------------------------------------
(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
r Federal su
l
t
f
t
i
b
UNIT PRICE
AMOUNT
No. and Date of
Date of Delivery
pp
y
rac
o
er o
con
tem num
(Enter description
and other information deemed necessary)
schedule
QUANTITY
-
Order
or Service
,
Cost
Per
Dollars
Cts.
Discount Terms
Costs
$16
60
PAYMENT:
Complete ^
Partial ^
Final ^
Use continuation. sheet(s) if necessary
_
Shipped from to Weight Government
B/L No. Total
$16
60-
(Payee must NOT use this space)
I certify that the above bill is correct and just and that payment has not been received.
Differences ---------------------------------
---------------
-----
(Sign original only)
-----
Date
-----------------------------------------------
-------------
---
-----
equlred when a like eertlsoete i, m de by payee on attaehod bill or bill.)
_______
Amount verified; correct for ____
Contract No. / of / Date Req. No.
~~j ~
(Signature or initials )6L
Pursuant to authority vested in me, I certify that this account is correct and proper for payment.
f Approved for $- --------------------------------- t ------------------------------------------------------------------------------
(Authorized Certifying Officer)
SIGN
ORIGINAL Title --------------------------------------------------------------------------
By ------------------------------------------------------------ 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 $-------------------------------------- Ion Treasurer of the United States in favor of
Paid by I lpayce named above.
Cash, $ -- on -------------------------------------- 19 - Payee - - (eig---n--------only)
or,eina1
-----------------------------
W a voucher feted i tlh@ n~ P ti tie ned writ neothe ompanssit f3i~ece no 1 YliA Py~lDifV ESs nl{I1 -
fM1JW Ut00600040164-T---------------------------------------
P
essary; otherwise the approving officer will sign on the lino below "Approved for $--------------------- ", and
over his official title.
Title -------------------------------------------------------
re-22900-e
 Approved For Release 2001/08/15 : CIA-RDP64-0036OR000600040164-1
Approved For Release 2001/08/15 : CIA-RDP64-0036OR000600040164-1