Purchase Voucher for Purchases and Services Other Than Personal (Schedule C)

06/26/2012


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    
             

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