This instrument was developed for the National Long-Term Care Channeling Demonstration. This project was conducted by Mathematica Policy Research, Inc. under contract #HHS-100-80-0157 and Temple University under contract #HHS-100-80-0133 for the Department of Health and Human Services (HHS) Office of Social Services Policy (now Office of Disability, Aging and Long-Term Care Policy), as well as additional funding from the HHS Health Care Financing Administration (now Centers for Medicare and Medicaid Services) and HHS Administration on Aging. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.
| NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form. |
| SCHEDULE C | ||||||
| Standard Form 1034 7 GAO 5000 1034-114 | PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL | VOUCHER NO. | ||||
| U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION | DATE VOUCHER PREPARED | SCHEUDULE NO. | ||||
| CONTRACT NUMBER AND DATE | PAID BY | |||||
| REQUISITION NUMBER AND DATE | ||||||
| PAYEE'S NAME AND ADDRESS | ||||||
| DATE INVOICE RECEIVED | ||||||
| DISCOUNT TERMS | ||||||
| PAYEE'S ACCOUNT NUMBER | ||||||
| SHIPPED FROM | TO | WEIGHT | GOVERNMENT 8/L NUMBER | |||
| NUMBER AND DATE OR ORDER | DATE OF DELIVERY OR SERVICE | ARTICLES OR SERVICES (Enter description, item number of coutract or Federal supply schedule, and other information deemed necessary) | QUAN- TITY | UNIT PRICE | AMOUNT | |
| COST | PER | (1) | ||||
| (Use continuation sheet(s) if necessary) (Payee must NOT use the space below) TOTAL | ||||||
| PAYMENT: _____ COMPLETE _____ PARTIAL _____ FINAL _____ PROGRESS _____ ADVANCE | APPROVED FOR = $ | EXCHANGE RATE = $1.00 | DIFFERENCES | |||
| BY: | ||||||
| TITLE | Amount verified: correct for | |||||
| (Signature or initials) | ||||||
| Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment. (Date) _________________________ (Authorized Certifying Officer)2 _________________________ (Title) _________________________ | ||||||
| ACCOUNTING CLASSIFICATION | ||||||
| PAID BY: | ||||||
| CHECK NUMBER | ON TREASURER OF THE UNITED STATES | CHECK NUMBER | ON (Name of bank) | |||
| CASH $ | DATE | PAYEE3 | ||||
| 1. When stated in foreign currency, insert name of currency. 2. If the ability to certify and authority to approve are combined in one person, one signature only is necessary; otherwise the approving officer will sign in the space provided, over his official title. 3. When a voucher is receipted in the name of a company or corporation, the name of person writing the company or corporate name, as well as the capacity in which he signs, must appear. For example, "John Doe Company, per John Smith, Secretary", or "Treasurer", as the case may be. | PER | |||||
| TITLE | ||||||
| Standard Form 1034 7 GAO 5000 1034-114 | PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL CONTINUATION SHEET | VOUCHER NO. | ||||
| SCHEUDULE NO. | ||||||
| SHEET NO. | ||||||
| U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION | ||||||
| NUMBER AND DATE OR ORDER | DATE OF DELIVERY OR SERVICE | ARTICLES OR SERVICES (Enter description, item number of coutract or Federal supply schedule, and other information deemed necessary) | QUAN- TITY | UNIT PRICE | AMOUNT | |
| COST | PER | |||||