Spreadsheet: 0e417484-5fcd-41d0-9698-bcac21d315cc
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | This page number | Unnamed: 8 | Unnamed: 9 | O | Total number of pages | Unnamed: 12 | Unnamed: 13 | Requisition number | Unnamed: 15 | Unnamed: 16 | Date of requisition
 |  |  |  |  |  |  |  |  |  | F
 |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME] number
 |  |  |  |  |  |  | [NAME] date |  |  |  | Required Delivery Date
 | This is the |  | ______ | partial delivery reported on this order. |  |  | I.D.O.A. Identification Number |  |  |  |  |  |  | Fund | Account | [NAME] | Project
 |  |  |  |  |  |  | Vendor Identification Number |  |  |  |  |  |  | Business Unit | Program | Department | Activity
Name & address of vendor:
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Name of requesting Business Unit / Approp. name
Delivered to: |  |  |  |  |  |  |  |  |  |  |  |  |  | INSTRUCTIONS:
 |  |  |  |  |  |  |  |  |  |  |  |  |  | Use this form only for reporting partial deliveries on a [NAME].  Use the receiving copy of the Purchase Order for reporting the final delivery on the order.  Forward this report without delay to:
 |  |  |  |  |  |  |  |  |  |  |  |  |  | AUDITOR OF STATE
 |  |  |  |  |  |  |  |  |  |  |  |  |  | 200 W WASHINGTON ST RM 144
 |  |  |  |  |  |  |  |  |  |  |  |  |  | INDIANAPOLIS, IN 46204
 |  |  |  |  |  |  |  |  |  |  |  |  |  | This document authorizes the Auditor to pay the claim.
 |  | F.O.B. DESTINATION unless otherwise stated below |  |  |  |  | NOTICE:  No price corrections will be permitted after issuance of this Purchase Order.
Contract |  |  | UNIT |  | ARTICLE and [NAME] |  |  |  |  |  |  | UNIT PRICE |  |  | AMOUNT
Line |  |  |  | QUANTITY
Item |  |  |  | RECEIVED
No.
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 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  | Please pay this amount: |  |  |  | 0
REQUESTING BUSINESS UNIT'S CERTIFICATION OF RECEIPT AND COMPLIANCE
Confirmation of Receipt |  |  |  |  |  |  |  |  | Approval for Payment
I certify that the items listed above were received and checked by me on the date indicated.  All commodities appeared to conform to specifications and showed no patent defects, except as otherwise noted. |  |  |  |  |  |  |  |  | I certify that the vendor has performed in accordance with the terms and contract obligations pertaining to the Purchase Order, and hereby authorize and approve payment of appropriate claims.
Signature of Receiver |  |  |  |  | Typed / printed name |  |  |  | Authorized Signature for Business Unit |  |  |  |  |  | Typed / printed name
 |  |  |  |  | Date signed (month, day, year) |  |  |  |  |  |  |  |  |  | Date signed (month, day, year)