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(When Filled In)
REIMBURSEMENT VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL
NAME OF CLAIMANT (C)
CHARGE TO ALLOTMENT OR PROJECT
Voucher No. 52
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 #21, 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.
400.00
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.
OBLIGATION REFERENCE NO.
CHARGE ALLOTMENT NO.
APPROVED