(When Filled In)
REIMBURSEMENT VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL
NAME OF CLAIMANT (C)
CHARGE TO ALLOTMENT OR PROJECT
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
AMOUNT
Payment to [redacted] for MOUTRA Sub-project #52, Invoice #22, per paragraph IV D of the MOUTRA 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 materials 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 1 July 1963
$300.00
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.
CHARGE ALLOTMENT NO.
DATE
SIGNATURE OF AUTHORIZING OFFICER
APPROVED
DATE
SIGNATURE OF APPROVING OFFICER
CERTIFIED FOR PAYMENT OR CREDIT
DATE
SIGNATURE OF CERTIFYING OFFICER
PAYMENT RECEIVED IN THE AMOUNT OF $
DATE
SIGNATURE OF PAYEE (A)
SIGNATURE OF RECIPIENT
SPACE BELOW FOR EXCLUSIVE USE OF FINANCE DIVISION
PREPARED BY
REVIEWED BY
Voucher No. 7-12
13-39
40-42
45-46
47-52
53
54-57
59-67
68-70
71-80
DESCRIPTION - ALL OTHER ACCOUNTS
EXPEND CODE
PAY PER. LIQ. CODE
OBLIG. REF. NO. ADVANCE ACCT. NO. EXP. NO.
GENERAL LEDGER ACCT. NO.
ALLOT. LEDGER ACCT. NO. CR. NO. X 100,000
DUE DATE
OBJECT CLASS
AMOUNT
DESCRIPTION - A/P ITEMS 13-33
34-39
DESCRIPTION - ADVANCE ACCOUNTS 13-24
PAYABLE VOU. NO.
FORM NO. 264 USE PREVIOUS EDITIONS.
DEC 55
(49)
52-14