ࡱ> M 3bjbj== DWWc[lPPPP($N|$|$|$P$%TNcz'...XB/;$=T?bbbbbbb$!e Agb@?B9 ; @,7@b OPP*/B/C ac O O OO@Pl*/B/b O?b OJ OWQrPZT,P[*/ ' ȒN.|$9E8Z^[,wc0cZgqJgP[ O 6PPPPVoucher Number  FORMTEXT      `$Originating Agency (limit to 30 spaces)  FORMTEXT      Orig. Agency Code  FORMTEXT      Interest Eligible (Y/N)  FORMTEXT  a$P-Contract  FORMTEXT      Payment Date (MM/DD/YY)  FORMTEXT      OSC Use OnlyLiability Date (MM/DD/YY)  FORMTEXT      b$Payee ID  FORMTEXT      Additional  FORMTEXT      Zip Code  FORMTEXT      Route  FORMTEXT    Payee Amount  FORMTEXT      MIR Date (MM/DD/YY)  FORMTEXT      c$Payee Name (limit to 30 spaces)  FORMTEXT      IRS Code  FORMTEXT   IRS Amount  FORMTEXT      Payee Name (limit to 30 spaces)  FORMTEXT      Stat. Type  FORMTEXT      Statistic  FORMTEXT      Indicator-Dept.  FORMTEXT      Indicator-Statewide  FORMTEXT      Address (limit to 30 spaces)  FORMTEXT      d$Ref/Inv. No. (Limit to 20 spaces)  FORMTEXT      Address (limit to 30 spaces)  FORMTEXT      Ref/Inv. Date (MM/DD/YY)  FORMTEXT      City (Limit to 20 spaces) (Limit to 2 spaces)(  FORMTEXT      State  FORMTEXT   Zip Code  FORMTEXT       FORMTEXT       e$Purchase Order No. and DateDescription of Material/Service If items are too numerous to be incorporated into the block below, use Form AC 93 and carry total forward.QuantityUnitPriceAmount FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty*price 0$0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty2*price2 0$0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty3*price3 0$0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty4*price4 0$0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty5*price5 0$0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty6*price6 0$0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty7*price7 0$0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty8*price8 0$0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty9*price9 0$0.00 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  =qty10*price10 0$0.00 f$Payee Certification I certify that the above bill is just, true and correct; that no part thereof has been paid except as stated and that the balance is actually due and owing, and that taxes from which the State is exempt are excluded.  FORMTEXT        Payee s Signature in Ink Title  FORMTEXT        FORMTEXT        Date Name of CompanyTotal  FORMTEXT  =SUM(Table1 f2:f11) $0.00$0.00Discount % FORMTEXT      FORMTEXT  =c1*b3 $0.00-$0.00Net FORMTEXT  =SUM(c1:c3) $0.00$0.00For Agency Use OnlyState Comptrollers Pre-AuditMerchandise Received  Date  Page No.  ByI certify that this voucher is correct and just, and payment is approved, and the goods or services rendered or furnished are for use in the performance of the official functions and duties of this agency. Authorized Signature in Ink Date Title Certified for payment of total amount By Verified  Audited  Special Approval (as Required)ExpenditureLiquidationCost Center CodeObjectAccumAmountOrig. AgencyPO/ContractLineF/PDeptCost Center UnitVarYrDeptStatewideDistribution: Original to OSC with Copy to Agency/Department and Payee   FORMCHECKBOX  Check if Continuation form is attached. Above Form MUST print on one page NOTICE TO VENDORS OF SALES TAX EXEMPTION This sheet may be retained by vendor and can be presented as proof of exemption from New York State and local sales taxes. INSTRUCTIONS TO VENDORS PREPARING VOUCHERS The numbered paragraphs below refer to the numbered blocks on the face of this form, which are to be completed. Notice to vendors: Do not complete any blocks other than the following. Originating Agency: Insert name of State Department, Agency or institution being billed, as shown at the top of the Purchase Order. P-Contract: Enter here the P-Contract Number, if any, under which the purchase is made, e.g. P010966. Do not use hyphens or spaces. NOTE: TO AVOID PROBLEMS WITH IRS, FOLLOW INSTRUCTIONS FOR BLOCKS 3 AND 4 CAREFULLY. Payee I.D./Additional/Zip Code: Enter your Federal Employer Identification Number (EIN). If you do not have an EIN, enter your Social Security Number. Do not use hyphens or spaces. If you were assigned a Payee Additional Code by New York State, enter this in the box marked Additional. Enter your nine position Zip+4 in the adjacent block only if you have been assigned an Additional Code. Payee Name and Address: For individuals or sole proprietors, enter your name (exactly as it appears on your Social Security card) in the first Payee Name block. If there is a business name or DBA, Enter that information in the second Payee Name block. Corporations, partnerships and tax exempt organizations should enter the name of the entity (exactly as registered with the Federal government) that corresponds to the EIN entered in Block 3. Enter your proper mailing address conforming to U.S. Postal Standards. Include either your five-position zip code or your Zip+4 in your address. Ref./Inv. No.: Enter a reference number, invoice number, or other information. This information WILL APPEAR ON THE CHECK STUB and will identify the payment. Do not exceed 30 characters including letters, numbers, spaces, commas, etc. The check stub issued to you will contain the information you furnished in this block, and may be compared to this copy of the voucher, which you will detach and keep. Enter the corresponding reference/invoice date in the block below the Ref./Inv. No. block. Description of Material/Service: Enter all pertinent information required by the specific column headings. Extend calculations into Amount column. VENDORS OPTION: Any company that has its own invoice or bill form may refer to it by number or other identification in the Ref./Inv. No. block. In addition, write See Invoice Attached in the description block, and show the total in the amount column. Attach invoices in duplicate to this voucher. Payee Certification: Clearly indicate the title of the person signing for the payee, e.g., sole owner, partner, treasure, bookkeeper, billing clerk, etc. PAGE \# "'Page: '#' '" Either print this form and fill-in manually or enter information in highlighted fields. When entering information into form fields, do not allow the page to break. Form and all information MUST print on one page. For additional instructions on completion of this form see page 2. PAGE \# "'Page: '#' '"  PAGE \# "'Page: '#' '"  PAGE \# "'Page: '#' '" Quantity and Price MUST have input data for the amount field to calculate. Use the TAB key to move from field to field. The Net field will calculate and deduct the discount if the preparer enters a value and tabs out of the Discount field. REVIEW ALL DATA ENTERED AND TOTALS FOR ACCURACY. PAGE \# "'Page: '#' '" Quantity and Price must be input for the amount to calculate. Use the TAB key to move from field to field. PAGE \# "'Page: '#' '" If a discount is to be applied to the total amount of the voucher, it MUST be entered as a DECIMAL. (ex. Enter 7% as .07) PAGE \# "'Page: '#' '" If a discount is to be applied to the total amount of the voucher, it MUST be entered as a DECIMAL. (ex. 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