PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP64-00360R000600040190-2
• Release Decision: RIPPUB
• Original Classification: K
• Document Page Count: 4
• Document Creation Date: December 9, 2016
• Document Release Date: June 2, 2001
• Sequence Number: 190
• Publication Date: February 2, 1959
• Content Type: FORM

i3tandarct ~rn1 No. 1034-Revised
Date ---2-2-~,~ --- *-Payee -------------------------------------------------------------------------- ------------ ~
00040190-2 p
Bu. Vou. No. -------fL)-"ZSQ------------------
COST REIMBURSABLE
U. S. -----------------------------------------------------------~--------------------------------------------------------------------
(Department, bureau, or establishment)
Voucher prepared of --------------------------------------------------------------------------------------------------------
(Cive place and data)
THE UNITED STATES, Dr., Payee's Account No. ________________
Po -------------------------------------------------------------------------------------- --------------------------------------------
(Payee)
(Address) (City) (State)
r ( -Form proscribed b~I- ~~c~~~ln~~+
GomptroAcr (}oney~ pl`SOved For Re !1}C/4, ~r
September 7, ~~
(3en. Reg. No. 61, Supp. o, 11)
(Amended February 20, 1962)
ARTICLES OR SERVICES
UNIT PRICE
AMOUNT
nd Date of
N
Dato of Delivery
(Enter description Item number of contract or Federal supply
A
T
o. a
O
d
or Servlco
schedule, ant other information deemed necessary)
QU
NTI
Y
-
r
er
Cost
Por
Dollars
Cts.
Discount Terms
Costs
227,
70
PAYNENT:
Complete ^
Partial ^
~'
Final ^
Uae continuation sheet(s) if necessary
Shipped from to Weight Government B/L No.
_
Total
227.
_
70
--
(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)
--- Title ----------------------------------------------I (Signature or initials) --------------------------------
Contract No ~O Date Req. No. Date Invoice Recd.
Pursuant to authority vested in me, I certify that this account is correct and proper for payment.
SIGN
ORIGINAL
ONLY
fi ------------------------------------------Y - g -------~-----------------------
(Authorized Certif in Officer ~
Title ------?-------------------------------------------------- Date --------------------------?----------------------------------------------
T[!E 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 ~_____________________________________. Jon Treasurer of the United States in favor at
Paid by ) jpayee named above.
Cash, $------------------------? on ------------------------'---------... 19-----. Payee -------------------------------------------------------------------------
(91en ocieiuwl ody)
' When a voucher is si ed or receipt d ' the am of a com a or cor oration, the name of the erson
`~`~~~e~1~;~. E~~~R?P6~0~? 6~~RODDFDUU4U'i9D=~-----------------------------------
writing the company or ns
"John Doo Company, per n mit ,Secretary' , or reasuror ', as t e case may e.
t If the ability to certify and authority to approve are combined in one person, one signature only is nee- Title __________________________________________________
essary; otherwise the approving ofbaerwdll,~>gn on ~ie,line below "Approved for $______-____________", and io-zzgoo-a
over his official title. ~ ~
 Approved For Release 2001/08/15 :CIA-RDP64-003608000600040190-2
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