State of New Jersey

PAYMENT VOUCHER

(Vendor Invoice)	DOCUMENT	BATCH	ACTG PER	FY
TC	AGY	NUMBER	TC	AGY	NUMBER
PP START	SCHED PAY	CHK CAT	OFF LIAB	F

A	RF TY	CK FL	(A) VENDOR (PAYEE)

ID NUMBER
PO#	PV DATE	MO	DY	YR	MO	DY	YR
V
CONTRACT NO.	AGENCY REF	BUYER	(B) TERMS	(C) TOTAL AMOUNT
(D) PAYEE NAME AND ADDRESS

(D) SEND COMPLETED FORM TO:

NJ Department of Health

Infectious and Zoonotic Dis Prog

PO Box 369

Trenton, NJ 08625-0369
(F) PAYEE DECLARATIONS

I CERTIFY THAT THE WITHIN PAYMENT VOUCHER IS CORRECT IN ALL ITS PARTICULARS, THAT THE DESCRIBED GOODS OR SERVICES HAVE BEEN FURNISHED OR RENDERED AND THAT NO BONUS HAS BEEN GIVEN OR RECEIVED ON ACCOUNT OF SAID DOCUMENT.	((((
PAYEE SIGNATURE
PAYEE TITLE	BILLING DATE

REERENCE	LINE	(G) PAYEE REFERENCE
CD	AGY	NUMBER
SURGERIES MONTH OF

FUND	AGCY	ORG CODE	SUB-ORG	APPR UNIT	ACTIVITY CD	OBJECT CD	SUB-OBJ	REV SRCE	SUB-REV	PROJ/JOB NO

RPT CT	BS ACT	DT	DESCRIPTION	QUANTITY	AMOUNT	ID	PF	TX

PAYMENT VOUCHER (INVOICE) TO BE SUBMITTED 10 DAYS FROM THE END OF THE MONTH OF SURGERY.

description OF ITEM	unit price	amount
Commodity Code: 79445
[ ] PUBLIC ASSISTANCE [ ] SHELTER ADOPTION
Number of Female Dogs	0-25 lbs.	@
26-50 lbs.	@
51-75 lbs.	@
Over 75 lbs.	@
Number of Female Cats of Any Weight	@
Number of Male Dogs	0-25 lbs.	@
26-50 lbs.	@
51-75 lbs.	@
Over 75 lbs.	@
Number of Male Cats of Any Weight	@
Sub-Total
X 80%
Reimbursement for Surgeries
Number of Pets Vaccinated	@
$10.00
TOTAL

CERTIFICATION BY RECEIVING AGENCY: I certify that the above articles have been received or services rendered as stated herein.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Title Date	CERTIFICATION BY APPROVAL OFFICER: I certify that this Payment Voucher is correct and just, and payment is approved.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Authorized Signature

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Title Date
APC-7 AUG 12	Distribution: Original and 2 copies to NJDOH

NJDOH