<table>
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="10">Standard Form 1034</td>
<td colspan="21"></td>
<td colspan="6">VOUCHER NO.</td>
</tr>
<tr class="even">
<td colspan="10">Revised January 1980</td>
<td colspan="21"><strong>PUBLIC VOUCHER FOR PURCHASES AND</strong></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="10">Department of the Treasury</td>
<td colspan="21"><strong>SERVICES OTHER THAN PERSONAL</strong></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="10">I TFRM 4-2000</td>
<td colspan="21"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="17">U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND
LOCATION</td>
<td colspan="14">DATE VOUCHER PREPARED</td>
<td colspan="6">SCHEDULE NO.</td>
</tr>
<tr class="even">
<td colspan="17"><strong>NASA/Goddard Space Flight Center</strong></td>
<td colspan="14"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="17"><strong>Greenbelt, MD 20771</strong></td>
<td colspan="14">CONTRACT NUMBER AND DATE</td>
<td colspan="6"><strong>PAID BY</strong></td>
</tr>
<tr class="even">
<td colspan="17"></td>
<td colspan="14"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="17"></td>
<td colspan="14">REQUISITION NUMBER AND DATE</td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="17"></td>
<td colspan="14"> P.O. #</td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="26"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="4"></td>
<td colspan="14"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="26"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="5"><strong>PAYEE’S</strong></td>
<td colspan="26">Code</td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>NAME</strong></td>
<td colspan="26"></td>
<td colspan="6">DATE INVOICE RECEIVED</td>
</tr>
<tr class="even">
<td colspan="5"><strong>AND</strong></td>
<td colspan="26"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>ADDRESS</strong></td>
<td colspan="26"></td>
<td colspan="6">DISCOUNT TERMS</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="26"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="4"></td>
<td colspan="14"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="6">PAYEE’S ACCOUNT NUMBER</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="26"></td>
<td colspan="6">P.O. #</td>
</tr>
<tr class="odd">
<td colspan="12">SHIPPED FROM</td>
<td colspan="8">TO</td>
<td colspan="11">WEIGHT</td>
<td colspan="6">GOVERNMENT B/L NUMBER</td>
</tr>
<tr class="even">
<td colspan="12"></td>
<td colspan="8"></td>
<td colspan="11"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="4">NUMBER</td>
<td colspan="7">DATE OF</td>
<td colspan="11">ARTICLES OR SERVICES</td>
<td colspan="6"></td>
<td colspan="6">UNIT PRICE</td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4">AND DATE</td>
<td colspan="7">DELIVERY</td>
<td colspan="11"><em>(Enter description, item number of contract or
Federal supply</em></td>
<td colspan="6">QUANTITY</td>
<td colspan="5">COST</td>
<td>PER</td>
<td colspan="3">AMOUNT</td>
</tr>
<tr class="odd">
<td colspan="4">OF ORDER</td>
<td colspan="7">OR SERVICE</td>
<td colspan="11"><em>schedule, and other information deemed
necessary)</em></td>
<td colspan="6"></td>
<td colspan="5"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="7"></td>
<td colspan="11"></td>
<td colspan="6"></td>
<td colspan="5"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="7"></td>
<td colspan="11"></td>
<td colspan="6"></td>
<td colspan="5"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="7"></td>
<td colspan="11"></td>
<td colspan="6"></td>
<td colspan="5"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="7"></td>
<td colspan="11"></td>
<td colspan="6"></td>
<td colspan="5"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="13">(Use continuation sheet(s) if necessary)</td>
<td colspan="17"><strong>(Payee must NOT use the space
below)</strong></td>
<td colspan="4"><strong>TOTAL</strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="7">PAYMENT:</td>
<td colspan="7"><strong>APPROVED FOR:</strong></td>
<td colspan="2"></td>
<td colspan="5"><strong>EXCHANGE RATE</strong></td>
<td colspan="3"></td>
<td colspan="8">DIFFERENCES</td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="7">PROVISIONAL</td>
<td colspan="7"></td>
<td colspan="2"><strong>=$</strong></td>
<td colspan="5"></td>
<td colspan="3"><strong>=$1.00</strong></td>
<td colspan="8"></td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="7">COMPLETE</td>
<td colspan="9"><strong>BY<sup>2</sup></strong></td>
<td colspan="8"></td>
<td colspan="10"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="7">PARTIAL</td>
<td colspan="9"></td>
<td colspan="8"></td>
<td colspan="10"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="7">FINAL</td>
<td colspan="9"></td>
<td colspan="8"></td>
<td colspan="10">Amount verified; correct for</td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="7">PROGRESS</td>
<td colspan="9"><strong>TITLE</strong></td>
<td colspan="8"></td>
<td colspan="13"><em>(Signature or initials)</em></td>
</tr>
<tr class="odd">
<td colspan="7">ADVANCE</td>
<td colspan="9"></td>
<td colspan="8"></td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="37">Pursuant to authority vested in me, I certify that this
voucher is correct and proper for payment.</td>
</tr>
<tr class="odd">
<td colspan="37"></td>
</tr>
<tr class="even">
<td colspan="37"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="11"></td>
<td></td>
<td colspan="16"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"><em>(Date)</em></td>
<td colspan="2"></td>
<td colspan="11"><em>(Authorized Certifying
Officer)<sup>2</sup></em></td>
<td></td>
<td colspan="16"><em>(Title)</em></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="37">ACCOUNTING CLASSIFICATION</td>
</tr>
<tr class="even">
<td colspan="37"><strong>Cost Ctr.:</strong> <strong>WBS:</strong>
<strong>Order:</strong> FC100103 <strong>Fund:</strong></td>
</tr>
<tr class="odd">
<td colspan="37"></td>
</tr>
<tr class="even">
<td colspan="37"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td></td>
<td colspan="9">CHECK NUMBER</td>
<td colspan="6">ON ACCOUNT OF U.S. TREASURY</td>
<td colspan="11">CHECK NUMBER</td>
<td colspan="8">ON <em>(Name of bank)</em></td>
</tr>
<tr class="even">
<td colspan="2"><strong>P</strong></td>
<td></td>
<td colspan="9"></td>
<td colspan="6"></td>
<td colspan="19"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>A</strong></td>
<td><strong>B</strong></td>
<td colspan="9"></td>
<td colspan="6"></td>
<td colspan="19"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>I</strong></td>
<td><strong>Y</strong></td>
<td colspan="9">CASH</td>
<td colspan="6">DATE</td>
<td colspan="19">PAYEE<sup>3</sup></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>D</strong></td>
<td></td>
<td colspan="9"></td>
<td colspan="6"></td>
<td colspan="19"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td></td>
<td colspan="9">$</td>
<td colspan="6"></td>
<td colspan="19"></td>
</tr>
<tr class="odd">
<td colspan="27"><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;</p>
<p>otherwise, the approving officer will sign in the space provided,
over his official title.</p></td>
<td colspan="10">PER</td>
</tr>
<tr class="even">
<td colspan="27"><p><sup>3</sup> When a voucher is receipted in the name
of a company or corporation, the name of the person writing the</p>
<p>company or corporate name, as well as the capacity in which he signs,
must appear. For example:</p>
<p>“John Doe Company, per John Smith, Secretary,” or “Treasurer,” as the
case may be.</p></td>
<td colspan="10">TITLE</td>
</tr>
<tr class="odd">
<td colspan="15">Previous edition usable</td>
<td colspan="10">1034-119</td>
<td colspan="12">NSN 7540-00-900-2234</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="31"><strong>PRIVACY ACT STATEMENT</strong></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="31">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.</td>
<td colspan="2"></td>
</tr>
</tbody>
</table>