<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"></td>
<td colspan="8"><p><strong>PUBLIC VOUCHER FOR PURCHASES AND</strong></p>
<p><strong>SERVICES OTHER THAN PERSONAL</strong></p></td>
<td colspan="8"><p>VOUCHER NO.</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="9" rowspan="3"><p>U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT
AND LOCATION</p>
<p>     </p></td>
<td colspan="4"><p>DATE VOUCHER PREPARED</p>
<p>     </p></td>
<td colspan="8"><p>SCHEDULE NO.</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="4"><p>CONTRACT NUMBER AND DATE</p>
<p>           </p></td>
<td colspan="8" rowspan="2"><p>PAID BY</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="4">REQUISITION NUMBER AND DATE            </td>
</tr>
<tr class="odd">
<td colspan="13" rowspan="4"><p>PAYEE'S NAME AND ADDRESS</p>
<p>     </p></td>
<td colspan="8" rowspan="2"><p>DATE INVOICE RECEIVED</p>
<p>     </p></td>
</tr>
<tr class="even">
</tr>
<tr class="odd">
<td colspan="8"><p>DISCOUNT TERMS</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="8"><p>PAYEE'S ACCOUNT NUMBER</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="7"><p>SHIPPED FROM:</p>
<p>     </p></td>
<td colspan="4"><p>TO:</p>
<p>     </p></td>
<td colspan="2"><p>WEIGHT:</p>
<p>     </p></td>
<td colspan="8"><p>GOVERNMENT B/L NUMBER</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3" rowspan="2"><p>NUMBER</p>
<p>AND DATE</p>
<p>OF ORDER</p></td>
<td colspan="3" rowspan="2"><p>DATE OF</p>
<p>DELIVERY</p>
<p>OR SERVICE</p></td>
<td colspan="7" rowspan="2"><p>ARTICLES OR SERVICES</p>
<p>(Enter description, item # of contract or Federal supply schedule,
and other information deemed necessary)</p></td>
<td colspan="3" rowspan="2"><p>QUAN-</p>
<p>TITY</p></td>
<td colspan="4">UNIT PRICE</td>
<td rowspan="2">AMOUNT<sub>(1)</sub></td>
</tr>
<tr class="odd">
<td colspan="2">COST</td>
<td colspan="2">PER</td>
</tr>
<tr class="even">
<td colspan="3"><p>         </p>
<p>         </p>
<p>         </p>
<p>         </p>
<p>         </p></td>
<td colspan="3"><p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p></td>
<td colspan="7"><p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p></td>
<td colspan="3"><p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p></td>
<td colspan="2"><p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p></td>
<td colspan="2"><p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p></td>
<td><p>$0.00</p>
<p>$0.00</p>
<p>$0.00</p>
<p>$0.00</p>
<p>$0.00</p></td>
</tr>
<tr class="odd">
<td colspan="20">(Use continuation sheet(s) if necessary) <strong>(Payee
must NOT use the space below)</strong> <strong>TOTAL</strong></td>
<td>$0.00</td>
</tr>
<tr class="even">
<td colspan="4"><p>PAYMENT:</p>
<p>     </p></td>
<td colspan="6"><p>APPROVED FOR</p>
<p>     </p></td>
<td colspan="4"><p>EXCHANGE RATE</p>
<p>     </p></td>
<td colspan="5"><p>DIFFERENCES</p>
<p>     </p></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="5"><p>P</p>
<p>A</p>
<p>I</p>
<p>D</p>
<p>B</p>
<p>Y</p></td>
<td colspan="2">PROVISIONAL</td>
<td colspan="10" rowspan="3">BY:      </td>
<td colspan="5" rowspan="3"><p>AMOUNT VERIFIED; CORRECT FOR</p>
<p>     </p></td>
<td colspan="2" rowspan="3"></td>
</tr>
<tr class="even">
<td colspan="2">PARTIAL</td>
</tr>
<tr class="odd">
<td colspan="2">FINAL</td>
</tr>
<tr class="even">
<td colspan="2">PROGRESS</td>
<td colspan="10" rowspan="2">TITLE:</td>
<td colspan="7" rowspan="2">(SIGNATURE OR INITIALS)</td>
</tr>
<tr class="odd">
<td colspan="2">ADVANCE</td>
</tr>
<tr class="even">
<td colspan="21"><p>PURSUANT TO AUTHORITY VESTED IN ME, I CERTIFY THIS
VOUCHER IS CORRECT AND PROPER FOR PAYMENT.</p>
<p>(DATE) (AUTHORIZED CERTIFYING OFFICER)             (TITLE)
     </p></td>
</tr>
<tr class="odd">
<td colspan="21">ACCOUNTING CLASSIFICATION</td>
</tr>
<tr class="even">
<td colspan="21"><p><u>DOC NO</u> <u>EARMARK</u> <u>CURRCODE</u>
<u>CURRENCY</u> <u>FUNDING</u></p>
<p>                             </p></td>
</tr>
<tr class="odd">
<td rowspan="2"></td>
<td colspan="7"><p>CHECK NUMBER</p>
<p>     </p></td>
<td colspan="4">ON ACCOUNT OF U.S. TREASURY      </td>
<td colspan="5"><p>CHECK NUMBER</p>
<p>     </p></td>
<td colspan="4"><p>ON (Name of Bank)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="7"><p>CASH</p>
<p>     </p></td>
<td colspan="4"><p>DATE</p>
<p>     </p></td>
<td colspan="9"><p>PAYEE</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="15" rowspan="2"><p><sup>1</sup>When stated in foreign
currency, insert name of currency.</p>
<p><sup>2</sup>If the ability to certify and authority to approve are
combined in one person, one signature only is necessary. Otherwise the
approving officer will sign in the space provided, over his official
title.</p>
<p><sup>3</sup>When a voucher is receipted in the name of a company or
corporation, the name of the person writing the company or corporate
name, as well as the capacity in which he signs, must appear. For
example: "John Doe Company, per John Smith, Secretary", or "Treasurer",
as the case may be.</p></td>
<td colspan="6"><p>PER</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="6"><p>TITLE</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="21">Previous edition usable NSN 7540-00-900-2234</td>
</tr>
<tr class="even">
<td colspan="21"><p>PRIVACY ACT STATEMENT</p>
<p>The information requested on this form is required under the
provisions of 31 U.S.C. 82b and 82c, for the purpose of disbursing
Federal money. the information requested is to identify the particular
creditor and the amounts to be paid. Failure to furnish this information
will hinder discharge of the payment obligation.</p></td>
</tr>
</tbody>
</table>

Standard Form 1034 1987Department of the Treasury

Revised October 1987 1 TFM 4-2000 1034-121