Voucher Form

Standard Form 1034 September 1973 Treasury FRM 2000		PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL							VOUCHER NO.
U.S. DEPARTMENT, BUREAU OR ESTABLISHMENT AND LOCATION U.S. Department of Commerce Bureau of the Census Washington, DC 20233-9100				DATE VOUCHER PREPARED					SCHEDULE NO.
				CONTRACT NUMBER AND DATE					PAID BY
				REQ. NUMBER AND DATE
PLEASE PRINT NAME & ADDRESS BELOW: PAYEE=S NAME AND ADDRESS
									DATE INVOICE RECEIVED
									DISCOUNT TERMS
									PAYEE=S ACCOUNT NUMBER
SHIPPED FROM TO WEIGHT									GOVERNMENT B/L NUMBER
NUMBER AND DATE OF ORDER	DATE OF DELIVERY OR SERVICE	ARTICLES OR SERVICES (Enter description, item number of contract or Federal supply schedule, and other information deemed necessary)			QUAN-TITY		UNIT PRICE		AMOUNT
							COST	PER
		For participating in a cognitive interview as part of research on the NYCHVS. Center for Behavioral Science Methods Received by:______________________ Date: ________________________________________							$40.00
(Use continuation sheet(s) if necessary) (Payee must NOT use the space below) TOTAL
PAYMENT:  COMPLETE  PARTIAL  FINAL  PROGRESS  ADVANCE	APPROVED FOR $40.00		EXCHANGE RATE = $1.00			DIFFERENCES
	BY:
	TITLE:				Amount verified correct for				$40.00
					(Signature or initials)
Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment _____________________ _______________________________________________________________________ Social Science Analyst (Date) (Authorized Certifying Officer) (Title)
ACCOUNTING CLASSIFICATION
Project/Task: 5907054-000; Organizational Code: 11-29-0091-50-50-00-00; Obj. Class: 25-20-04-00
CHECK NUMBER ON TREASURER OF THE UNITED STATES				CHECK NUMBER ON (Name of Bank)
CASH DATE				PAYEE
PER				TITLE