Voucher

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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 cognitive interview to improve the NSCH.

Directorate for Demographic Programs
Demographic Statistical Methods Division
Survey Methodology Pool

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

_____________________                   _______________________________________________________________________           ____________________________________________              (Date)                                                     (Authorized Certifying Officer)                                                                            (Title)

	ACCOUNTING CLASSIFICATION

 Project/Task:              0977000-000; Organizational Code: 11-28-0087-50-50-00-00; Obj. Class: 25-10-02-00

CHECK NUMBER                ON TREASURER OF THE UNITED STATES

CHECK NUMBER                               ON (Name of Bank)


CASH                                        DATE

PAYEE

PER

TITLE