Form Ac 1171 - State Aid Voucher - Nys
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1AC 1171 (Rev 10/96)
STATE
STATE AID VOUCHER
OF
Voucher No.
NEW YORK
1
Originating Agency
Orig. Agency Code
Interest Eligible (Y/N)
Payment Date
OSC Use Only
Liability Date
(MM)
(DD)
(YY)
(MM)
(DD)
(YY)
/
/
/
/
Payee ID
Additional
Zip Code
Route Payee Amount
MIR Date (MM) (DD) (YY)
2
3
/
/
Payee Name (Limit to 30 spaces)
IRS Code
IRS Amount
4
Payee Name (Limit to 30 spaces)
Stat. Type
Statistic
Indicator-Dept.
Indicator-Statewide
Address (Limit to 30 spaces)
Ref/Inv. No. (Limit to 20 spaces)
5
Address (Limit to 30 spaces)
Ref/Inv. Date
(MM)
(DD)
(YY)
/
/
City (Limit to 20 spaces)
(Limit to 2 spaces) à State
Zip Code
6
Amount
Date
Check or
Description of Charges
Paid
Voucher No.
(If Personal Service, show name, title, period covered)
Dollars
Cents
7
State Aid Program or Applicable Statute:
TOTAL
8
Payee Certification:
Less Receipts
I certify that the above expenditures have been made in accordance with the provisions of the Applicable Statute; that the
claim is just and correct; that no part thereof has been paid except as stated; that the balance is actually due and owing,
and that taxes from which the State is exempt are excluded.
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NET
_________________________________________________________
_______________________________
Signature in Ink
Date
Title ____________________________________________________________________________________________
State Aid
_____% Claimed
Name of Municipality ______________________________________________________________________________
FOR STATE AGENCY USE ONLY
STATE COMPTROLLER’S PRE-AUDIT
Merchandise Received
I certify that this claim is correct and just, and payment is approved.
State
Aid
__________________________________________________________________________________
Date
Certified For Payment
By
Verified
of
State AId Amount
Page No.
__________________________________________________________________________________
Date
By ______________________________
By
Audited
Expenditure
Liquidation
Cost Center Code
Accum
Object
Amount
Orig. Agency
PO/Contract
Line
F/P
Dept.
Cost Center Unit
Var.
Yr.
Dept.
Statewide
Distribution: Original to OSC with Copy to Agency and Municipality
Check if Continuation form is attached
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