(When Filled In)
REIMBURSEMENT VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL
NAME OF CLAIMANT
[redacted]
Voucher No. (Finance use only)
[redacted]
CHARGE TO ALLOTMENT OR PROJECT
2125-1390-3902
REIMBURSEMENT OR PAYMENT IS CLAIMED FOR MATERIALS, SERVICES, OR OTHER EXPENDITURES ITEMIZED BELOW WHICH ARE PROPERLY CHARGEABLE TO THE ALLOTMENT OR PROJECT DESIGNATED.
DESCRIPTION OF EXPENDITURE - ATTACH RECEIPTS AND OTHER SUPPORTING DOCUMENTS
Payment to [redacted] for MULTRA Sub-Project #52, invoice #24, per paragraph IV-D of the MULTRA Fiscal Annex.
I certify that to the best of my knowledge and belief the amount shown as having been disbursed for Agency authorized activities and services or material have been received The documents upon which this statement is based are maintained in the files in TSD for security reasons and will be made available to the Certifying Officer upon his request.
$300.00
Pls forward check to C/TSD/DP thru TSD/DP no later than 27 December 1963
I CERTIFY THAT THIS VOUCHER AND ANY ATTACHMENTS ARE CORRECT, THE EXPENDITURES WERE INCURRED ON OFFICIAL BUSINESS OF A CONFIDENTIAL, EXTRAORDINARY, OR EMERGENCY NATURE; PAYMENT OR CREDIT HAS NOT BEEN RECEIVED, AND I SHALL NOT BE REIMBURSED FROM ANY OTHER SOURCE.
I CERTIFY FUNDS ARE AVAILABLE
OBLIGATION REFERENCE NO.
2125-1390-3902
CHARGE ALLOTMENT NO.
DATE
[redacted]
SIGNATURE OF AUTHORIZING OFFICER
[redacted]
APPROVED
DATE
12/16/63
SIGNATURE OF APPROVING OFFICER
SIDNEY COTTLETT, DC/TSD
CERTIFIED FOR PAYMENT OR CREDIT
DATE
[redacted]
SIGNATURE OF CERTIFYING OFFICER
[redacted]
PAYMENT RECEIVED IN THE AMOUNT OF $
DATE
[redacted]
SIGNATURE OF PAYEE
[redacted]
SIGNATURE OF RECIPIENT
[redacted]
SPACE BELOW FOR EXCLUSIVE USE OF FINANCE DIVISION
PREPARED BY
REVIEWED BY
Voucher No. 7-12
DESCRIPTION-ALL OTHER ACCOUNTS 13-33
34-39
40-42
43
45-46
47-52
53
54-57
58-67
68-70
71-80
STATION CODE
EXPEND CODE
FUNDS
PAY PER. LIO. CODE
OBLIG. REF. NO. - ADVANCE - ACCOUNT NO. EMP. NO.
GENERAL LEDGER ACCOUNT NO.
ALLOT. OR COST ACCT. NO.
DUE DATE
AMOUNT
DESCRIPTION-ADVANCE ACCOUNTS 13-27
34-39
40-42
43
45-46
47-52
53
54-57
58-67
68-70
71-80
STATION CODE
EXPEND CODE
FUNDS
PAY PER. LIO. CODE
OBLIG. REF. NO. - ADVANCE - ACCOUNT NO. EMP. NO.
GENERAL LEDGER ACCOUNT NO.
ALLOT. OR COST ACCT. NO.
DUE DATE
AMOUNT
TOTALS
FORM 264 USE PREVIOUS 6-59 EDITIONS.
(49)
52-11