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REIMBURSEMENT VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL
NAME OF CLAIMANT: [redacted]
CHARGE TO ALLOTMENT OR PROJECT: MKULTRA Sub 52
VOUCHER NO. (Finance use only)
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 MKULTRA Sub-Project #52, Invoice #23, per paragraph IV D of the MKULTRA 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 of TSD for security reasons and will be made available to the Certifying Officer upon his request.
Pls forward check to C/TSD/BB thru TSD/BF no later than 15 October 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.
OBLIGATION REFERENCE NO.
CHARGE ALLOTMENT NO.
DATE
SIGNATURE OF APPROVING OFFICER
APPROVED
DATE
SIGNATURE OF PAYEE
$200.00 998 | 1125-1390-3902
$100.00 841 | 2123-1390-3902
DATE
SIGNATURE OF AUTHORIZING OFFICER
CERTIFIED FOR PAYMENT OR CREDIT
SIGNATURE OF CERTIFYING OFFICER
DATE
SIGNATURE OF RECIPIENT
[redacted]
SIDNEY GOTTLIEB, DC/TSD
PAYMENT RECEIVED IN THE AMOUNT OF $300.00
PREPARED BY
REVIEWED BY
SPACE BELOW FOR EXCLUSIVE USE OF FINANCE DIVISION
VOUCHER NO. 7-12
DESCRIPTION-ALL OTHER ACCOUNTS 13-33
34-39 STATION CODE
40-42 EXPEND CODE
43 FUNDS
45-46 PAY PER. LID. CODE
47-52 OBLIG. REF. NO. - ADVANCE - ACCT. NO.
53 GENERAL LEDGER ACCOUNT NO.
54-57 ALLOT. OR COST ACCT. NO.
58-67 DUE DATE
68-70 AMOUNT
62-67 CR. NO. - ACCT. X REF. NO. CLASS
DEBIT
CREDIT
DESCRIPTION-ADVANCE ACCOUNTS 13-27