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
CONTRACT NO.	AGENCY REF	BUYER	(B) TERMS	(C) TOTAL AMOUNT
(D) PAYEE NAME AND ADDRESS

(E) SEND COMPLETED FORM TO:

(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

Line

No.	REFERENCE	LINE	(G) PAYEE REFERENCE
CD	AGY	NUMBER
1
2
3

FUND	AGCY	ORG CODE	SUB-ORG	APPR UNIT	ACTIVITY CD	OBJECT CD	SUB-OBJ	REV SRCE	SUB-REV	PROJ/JOB NO
1
2
3

RPT CT	BS ACT	DT	DESCRIPTION	QUANTITY	AMOUNT	ID	PF	TX
1
2
3

item No.	description OF ITEM	qUANTITY	UNIT	unit price	amount
TOTAL

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

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Signature

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

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Authorized Signature

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Title Date

PV 6/93 MAY 16

PV 6-93, Payment Voucher

voucher, PV 6-93, FS, PAYMENT VOUCHER, FINANCIAL SERVICES, Accounting and Procurement

EWhite

2016-04-11

NJDHSS