FUND-APPROPRIATION AMOUNT

CLAIMANT'S
NAME
AND
ADDRESS
Total $0.00
Ordered by : Purchase Order #

Date Amount

( Show any discounts that are allowed for prompt payment)

TOTAL
CLAIMANT'S CERTIFICATION

I, ______________________________________________ certify that the above account in the amount of $___________________ is

Date Signature Title

(Space below for municipal use)

The above services or materials were rendered or furnished to This claim is approved and ordered paid
from the appropriations indicated above.
correct

Date Authorized Official