Voucher Form

NSCH 2019 Content Voucher_OMB.docx

Generic Clearance for Questionnaire Pretesting Research

Voucher Form

OMB: 0607-0725

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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


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorRodney L Terry
File Modified0000-00-00
File Created2021-01-15

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