HomeMy WebLinkAboutFEMA REIMBURSEMENTS 2/23/2007-3/22007 I • i ' I I II II
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ittach s ipporting documentation
to the beck of this form S TA TE OF IO WA G AX
BUDGET FY PURCHASE ORDER/PAYMENT VOUCHERDOCUMENTNUMBEIR
DATE ACCTG PERIOD(mm/yy)
2008
/07
VENDOR CODE d SC trtr y, s 3.r i
AGENCY NAME
VENDOR NAME AND ADDRESS BILL TO ADDRESS(ORDERING AGENCY)
I )C. LOO, CI f Y O SHIP TO ADDRESS
f aMULBERRY . t'� .:I:'C' In.t il:.t`GC ;' t(td�.=tl�"ilr 04,E `'1`
WATERLOO," IA5070,3JOHN05 MIA TH AVE
5
TERMS FOB ORDER APPROVED BY GOODS RECEIVED/SERVICES
Phone Igo
1 OWA 1'1 t ii�..I -3ND �i?QFi7v1ECl`Y
Steve Lorenz Oct 24 n .-,0rER`, DAT INITIAL$
VENDOR'S INVOICE DATE VENDOR'S INVOICE NUMBER
QUANTITY
ORDERED RECEIVED UNIT OF DESCRIPTION
MEASURE UNIT PRICE TOTAL PRICE
1 .00 FA PUBLIC ASSISTANCE STATE SHARE 10815, 810
#COR sHEE(': 632
O
.00
' 00
4
00
.00
a00
00
•00
.00
.00
.00
00
.00
DOCUMENT TOTAL 1OFT3.8i
CLAIMANT'S CERTIFICATION
I CERTIFY THAT THE ITEMS FOR WHICH PAYMENT IS CLAIMED WERE FURNISHED FOR STATE AGENCY CERTIFICATION
BUSINESS UNDER THE AUTHORITY OF THE LAW AND THAT THE CHARGES ARE REASONABLE, I CERTIFY THAT THE ABOVE EXPENSES WERE INCURRED AND THE AMOUNTS ARE
PROPER,AND CORRECT,AND NO PART OF THIS CLAIM HAS BEEN PAID.
CLAIMANTS SIGNATURE CORRECT AND SHOULD BE PAID FROM THE FUNDS APPROPRIATED BY
AUTHORIZED SIGNATURE
THE FOLLOWING FIELDS ARE FOR STATE ACCOUNTING USE ONLY
DOC TYPE DOC NUMBER DOC DATE ACCTG PRD BUDGET
r� (PO or PV) ACTION PO SHIP PV
ti ! :�r 3 FY NEW/MOD INSTR TYPE IND INTSELLER NTSELLER
t' }83Oi__,:r._.t.,';_+ 1�;/23/0/ SI'Y q+0<05 C 1
FUND AGCY
VENDOR CODE ADDR OVERRIDE F/A INDICATOR EFT IND 0(x E
426005 270tA TE -db' only(Y/N)
TEXT(po's�;nly)
REF DOC TYPE REF DOC NUMBER REF DOC LINE COM LN
VEND INVOICE# I COMMODITY CODE
GS CONTRACT
LINE FUND AGCY ORG ORGSUB ACTV RSRC SUB FUNC r OBJT SUB JOB NUMBER REP QUANTITY/ I/D DESCRIPTION
RSRC OBJT CAT AM011NT f1D'PJF
0esr 7 i t «5 00 t UNITS ,
07-352 DOCUMENT TOTAL I
GAX WARRANT# AUDITED BY.f I ro-s,nz.
PAID DATE
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