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<tr class="odd">
<td colspan="8"><p>Standard Form 1034</p>
<p>Revised October 1987</p>
<p>Department of the Treasury</p>
<p>1 TFM 4-2000</p></td>
<td colspan="13"><h1 id="section"></h1>
<h1 id="public-voucher-for-purchases-and">PUBLIC VOUCHER FOR PURCHASES
AND</h1>
<p><strong>SERVICES OTHER THAN PERSONAL</strong></p></td>
<td colspan="2"><p>VOUCHER NO.</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="12" rowspan="3"><p>U.S. DEPARTMENT, BUREAU, OR
ESTABLISHMENT AND LOCATION</p>
<p><strong>U. S. Department of Energy</strong></p>
<p><strong>National Energy Technology Laboratory</strong></p>
<p><strong>Attn: Accounts Payable MS:      </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p></td>
<td colspan="9"><p>DATE VOUCHER PREPARED</p>
<p><strong>     </strong></p></td>
<td colspan="2"><p>SCHEDULE NO.</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="9"><p>CONTRACT NUMBER AND DATE</p>
<p><strong>     </strong></p></td>
<td colspan="2" rowspan="4"><h4 id="paid-by">PAID BY</h4></td>
</tr>
<tr class="even">
<td colspan="9"><p>REQUISITION NUMBER AND DATE</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="6"><h2 id="section-1"></h2>
<h2 id="payees">PAYEE’S</h2>
<p><strong>NAME</strong></p>
<p><strong>AND</strong></p>
<p><strong>ADDRESS</strong></p></td>
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="8" rowspan="4"><p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p></td>
<td colspan="3"></td>
<td colspan="3" rowspan="4"></td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="2"></td>
<td colspan="3" rowspan="2"></td>
<td colspan="2"><p>DATE INVOICE RECEIVED</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"><p>DISCOUNT TERMS</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="17"></td>
<td colspan="2"><p>PAYEE’S ACCOUNT NUMBER</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="21"><p>SHIPPED FROM TO WEIGHT</p>
<p>     </p></td>
<td colspan="2"><p>GOVERNMENT B/L NUMBER</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2"><p>NUMBER</p>
<p>AND DATE</p>
<p>OF ORDER</p></td>
<td colspan="5" rowspan="2"><p>DATE OF</p>
<p>DELIVERY</p>
<p>OR SERVICE</p></td>
<td colspan="6" rowspan="2"><p>ARTICLES OR SERVICES</p>
<p><em>(Enter description, item number of contract or Federal
supply</em></p>
<p><em>schedule, and other information deemed necessary)</em></p></td>
<td colspan="3" rowspan="2"><p>QUAN-</p>
<p>TITY</p></td>
<td colspan="3">UNIT PRICE</td>
<td rowspan="2">AMOUNT<sup>1</sup></td>
</tr>
<tr class="odd">
<td>COST</td>
<td colspan="2">PER</td>
</tr>
<tr class="even">
<td colspan="5"><p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p></td>
<td colspan="5"><p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p></td>
<td colspan="6"><p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p></td>
<td colspan="3"><p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p></td>
<td><p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p></td>
<td colspan="2"><p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p></td>
<td><p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="22">(Use continuation sheet(s) if necessary) <strong>(Payee
must NOT use the space below) TOTAL</strong></td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="6">PAYMENT:</td>
<td colspan="5" rowspan="2"><p>APPROVED FOR</p>
<p>=$</p></td>
<td colspan="3" rowspan="2"><p>EXCHANGE RATE</p>
<p>=$1.00</p></td>
<td colspan="8">DIFFERENCES</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="3">PROVISIONAL</td>
<td colspan="8"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="3">COMPLETE</td>
<td colspan="8" rowspan="3">BY <sup>2</sup></td>
<td colspan="8"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="3">PARTIAL</td>
<td colspan="8"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="3">FINAL</td>
<td colspan="8">Amount verified; correct for</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="3">PROGRESS</td>
<td colspan="8" rowspan="2">TITLE</td>
<td colspan="9" rowspan="2"><em>(Signature or initials)</em></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="3">ADVANCE</td>
</tr>
<tr class="odd">
<td colspan="14"><p>Pursuant to authority vested in me, I certify that
this voucher is correct and proper for payment.</p>
<p><strong>           </strong></p>
<p>_______________
___________________________________________________________</p>
<p><em>(Date) (Authorized Certifying Officer) <sup>2</sup></em></p></td>
<td colspan="9"><p><strong>     </strong></p>
<p><strong>________________________________________________</strong></p>
<p><em>(Title)</em></p></td>
</tr>
<tr class="even">
<td colspan="23">ACCOUNTING CLASSIFICATION</td>
</tr>
<tr class="odd">
<td colspan="23"></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"><h3 id="paid-by-1">PAID BY</h3></td>
<td colspan="11">CHECK NUMBER ON ACCOUNT OF U.S. TREASURY</td>
<td colspan="10">CHECK NUMBER ON <em>(Name of bank)</em></td>
</tr>
<tr class="odd">
<td colspan="11"><p>CASH DATE</p>
<p>$</p></td>
<td colspan="10">PAYEE <sup>3</sup></td>
</tr>
<tr class="even">
<td colspan="17" rowspan="2"><p>1 When stated in foreign currency,
insert name of currency.</p>
<p>2 If the ability to certify and authority to approve are combined in
one person, one signature only is necessary; otherwise</p>
<p>the approving officer will sign in the space provided, over his
official title.</p>
<p>3 When a voucher is receipted in the name of a company or
corporation, the name of the person writing the company or</p>
<p>corporate name, as well as the capacity in which he signs, must
appear. For example: “John Doe Company, per John</p>
<p>Smith, Secretary,” or “Treasurer,” as the case may be.</p></td>
<td colspan="6">PER</td>
</tr>
<tr class="odd">
<td colspan="6">TITLE</td>
</tr>
<tr class="even">
<td colspan="23">Previous edition usable. NSN 7540-00634-4206</td>
</tr>
<tr class="odd">
<td colspan="9"></td>
<td colspan="13"><h2 id="section-2"></h2>
<h2 id="privacy-act-statement">PRIVACY ACT STATEMENT</h2>
<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</p>
<p>Federal money. The information requested is to identify the
particular creditor and amounts to be paid. Failure to furnish this</p>
<p>information will hinder discharge of the payment obligation.</p></td>
<td></td>
</tr>
</tbody>
</table>