Form PR-20 Voucher for Work Performed Under Provisions of the Feder

This collection of information is Mandatory and will be used to reimburse State Departments of Transportation for costs incurred on Federal-aid projects. Public reporting burden is estimated to average
30 minutes per response, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control
number for this collection is 2125-0507. The expiration date for this OMB number is Nov. 30, 2007. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Highway Administration, 1200 New Jersey Avenue SE, Washington, DC, 20590.

Office of Management and Budget
Paperwork Reduction Project 2135-0507
Washington, D.C. 20503

Federal Highway Administration
Finance Division HCFM-30
1200 New Jersey Avenue SE
Washington, D.C. 20590
STATE VOUCHER NO.

U. S. Department
of Transportation
Federal Highway
Administration

VOUCHER FOR WORK PERFORMED
UNDER PROVISIONS OF THE FEDERAL AID
AND FEDERAL HIGHWAY ACTS,
AS AMENDED

FHWA VOUCHER NO.

APPROPRIATION

FHWA SCHEDULE NO.

THE UNITED STATES, DR., TO (Insert official or depositary named in project agreement)

PAID BY

ADDRESS

(For use of Paying Office)
STATE

VOUCHER TYPE (Check Appropriate Block)
CURRENT BILLING

VOUCHER PERIOD

FROM

OTHER PROGRESS

TO

FEDERAL AID PROJECT NO.

FINAL VOUCHER(*)

(*) Use Form FHWA-1447 for Final Voucher for a project constructed under certi fication acceptance or secondary road procedures (23 U.S.C. 117).
TOTAL ACTUAL COST

TOTAL
PARTICIPATING
COST

PRO-RATA OF
PARTICIPATING COST
CLAIMED FROM U.S.

TOTAL AMOUNT
CLAIMED
FROM U.S.

LESS
PREVIOUS
PAYMENTS

NET
AMOUNT
CLAIMED

I certify that the cost shown in this voucher have been incurred in accordance with terms of project agreements; applicable State and Federal laws or regulati ons; and
that no claim has previously been submitted for costs claimed.
STATE HIGHWAY AGENCY

DATE

SIGNATURE OF AUTHORIZED OFFICIAL

I certify that supporting records for costs claimed, and the
referenced project (if applicable), have been subjected to required
reviews, approvals and inspections by the Federal Highway
Administration and that the amount approve is justly due.
AMOUNT SUBMITTED
SIGNATURE OF FHWA REPRESENTATIVE
ADJUSTMENTS
AMOUNT APPROVED

FORM PR-20 (Rev. 8-07)

DATE APPROVED

PREVIOUS EDITIONS ARE OBSOLETE

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STATEMENT OF COSTS INCURRED UNDER PROJECT AGREEMENT
ITEM
NO.

ITEM

QUANTITY

UNIT

UNIT
PRICE

AMOUNT CARRIED FORWARD......

AMOUNT

NOTATIONS
(Payee must not
use this column)