Form PV Original: Audit & Control Copy: Department Accounting 53-0105
SUFFOLK COUNTY PAYMENT VOUCHER
Payment Voucher #
Responsible Agency
Entered By, Date
Single Check Indicator (Y/N)
Vendor Code (Tax ID) (10-1)
Accounting Period (mm/yy)
Budget FY (yy)
Document Total (Include Cents)
Vendor Name & Mailing Address:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Vendor Remit Address (if different):
___________________________________
___________________________________
___________________________________
___________________________________
Ln
(02)
Reference Document
Com
Ln#
(3)
Invoice
Fnd
(3)
Dept
(3)
Unit
(4)
Sub
Org
(2)
Actv
(4)
Obj
(4)
Sub
Obj
(2)
Rept
Cat
(4)
Capital
Project #
(8)
Cd (2) Number(11) Ln (2)
Number(12) Ln (3)
Rev (4)
BS Acct (4)
Description (17)
Amount (Include Cents)
I/D
P/F
01
02
03
04
05
06
Additional Com ments
DEPARTMENT CERTIFICATION: I herby certify that the materials above specified have been
received by me in good condition without substitution. The service pro perly performed and that the
quantities thereof have been verified with the exception of discrepan cies noted and payment is
approved.
PAYEE CERTIFICATION: I certify that the above bill is just, true and correct; that no part
thereof has been paid except as stated; that the balance is actually due and owing; that taxes
from which the County is exempt are excluded and that I have read an d am familiar with the
provisions of Local Law 32-1980 as detailed in the payee instruc tion section of this voucher.
SIGNED
DATE
TITLE
PAYEE’S SIGNATURE
TITLE
NAME OF COMPANY
reset form
$0.00