Form Wolfs-102 - Payment Voucher Vendor Signature
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1
2STATE OF WYOMING
WOLFS-102
APPROVAL:
PAYMENT VOUCHER
REV. 01/14/10
DOCUMENT APPROVAL
VENDOR SIGNATURE
SCREEN APPROVAL
DATE APPROVED
TRAN
AGENCY
ID NUMBER
BATCH ID:
MM
DD
YY
DOCUMENT ID:
GAX
BFY:
DATE:
VENDOR CLAIMANT INFORMATION
VENDOR NUMBER:
VC
IMPORTANT INSTRUCTIONS TO VENDOR
VENDOR NAME:
1. Payment cannot be made until this voucher is completed. Claims for payment must be
VENDOR ADDRESS:
fully itemized as to date and a complete description of goods/services provided.
2. Claimant must sign in ink under vendor certification.
3. Fill out in triplicate and return signed/completed original and one copy to applicable agency.
4. The invoice number will print on your warrant remittance advice. A copy of the
CITY
STATE
ZIP+4
payment voucher will not be returned.
5. THE STATE OF WYOMING IS TAX EXEMPT - 830208667
GOODS DELIVERED/SERVICES PERFORMED AT:
RETURN PAYMENT VOUCHER TO:
PURCHASE
VENDOR INVOICE
UNIT
DESCRIPTION OF GOODS OR SERVICES
QUANTITY
UNIT
AMOUNT
DATE
NUMBER
PRICE
PAYMENT VOUCHER CONTINUATION SHEET WOLFS-102A ATTACHED.
Vendor Discount Terms
TOTAL TO
Time in connection with discount offered will be computed from the date of delivery or from
-
PAY
date correct bill submitted on this form by vendor is received, whichever is later.
The Vendor certifies that no form of discrimination because of race, creed, color, sex, national origin or for any other reasons exist in the performance of the authorized services.
VENDOR CERTIFICATION
I certify, under penalty of perjury, that each item included in this voucher is correct, that the voucher contains no incorrect information, and that I have not previously received
payment for any item listed on this voucher.
Dated:
Claimant Signature in Ink, and Title
AGENCY AUTHORIZED USE ONLY
LINE EVENT
INVOICE
LINE DESCRIPTION
LINE AMOUNT
BY
FY
VENDOR INVOICE
NO
TYPE
LINE
01
INVOICE
DOC
DOC
VNDR COM ACCT
CHECK DESCRIPTION
REF TYPE
DATE
CODE
DEPT
DOCUMENT ID
LINE LINE
LINE
APPR
OBJ/
SUB
PROG
B/S
FUND
DEPT
UNIT
UNIT
REV
OBJ
REV
FUNCTION
PROGRAM
PHASE
PERIOD
ACCT
LINE EVENT
INVOICE
LINE DESCRIPTION
LINE AMOUNT
BY
FY
VENDOR INVOICE
NO
TYPE
LINE
02
INVOICE
DOC
DOC
VNDR COM ACCT
CHECK DESCRIPTION
REF TYPE
DATE
CODE
DEPT
DOCUMENT ID
LINE LINE
LINE
APPR
OBJ/
SUB
PROG
B/S
FUND
DEPT
UNIT
UNIT
REV
OBJ
REV
FUNCTION
PROGRAM
PHASE
PERIOD
ACCT
CONTINUATION CODING SHEET
PAYMENT VOUCHER APPROVAL
WOLFS-112 ATTACHED
I certify that this voucher and the items included herein
for payment are correct and just in all respects;
AGENCY OPTIONAL USE
Approval #1
By:
Approval #2
AGENCY APPROVAL
Date
Approval #3
Date Accepted
and that this voucher is approved for payment.
By:
Date
AGENCY DIRECTOR / DESIGNEE APPROVAL
THE STATE OF WYOMING IS AN EQUAL OPPORTUNITY EMPLOYER
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