Form Wolfs-102 - Payment Voucher - Vendor Certification
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1
2STATE OF WYOMING
WOLFS-102
APPROVAL:
PAYMENT VOUCHER
REV. 10/04/01
DOCUMENT APPROVAL
VENDOR SIGNATURE
SCREEN APPROVAL
DATE APPROVED
TRAN
AGENCY
ID NUMBER
BATCH ID:
MM
DD
YY
DOCUMENT ID:
P 1 F
BFY:
DATE:
VENDOR CLAIMANT INFORMATION
VENDOR NUMBER:
IMPORTANT INSTRUCTIONS TO VENDOR
VENDOR NAME:
1. Payment cannot be made until this voucher is completed. Claims for payment must be fully
VENDOR ADDRESS:
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 payment
CITY
STATE
ZIP+4
voucher will not be returned.
5. THE STATE OF WYOMING IS TAX EXEMPT - 830208667
Goods delivered/services performed at:
Return payment voucher to:
Purchase Date
Vendor Invoice Number
Description of Goods or Services
Quantity
Unit
Unit Price
Amount
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
PAY
from 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
LN
REFERENCE
SUB
NO
CD
AGY
NUMBER
LN
CLN
VENDOR INVOICE
FND
AGY
ORG
APPR UNIT
FUNC
OBJ/REV
OBJ
B/S ACCT
01
REPT
PROJECT NO.
CATG
DESCRIPTION
AMOUNT
LN
REFERENCE
SUB
NO
CD
AGY
NUMBER
LN
CLN
VENDOR INVOICE
FND
AGY
ORG
APPR UNIT
FUNC
OBJ/REV
OBJ
B/S ACCT
02
REPT
PROJECT NO.
CATG
DESCRIPTION
AMOUNT
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:
AGENCY DIRECTOR / DESIGNEE APPROVAL
Date
THE STATE OF WYOMING IS AN EQUAL OPPORTUNITY EMPLOYER
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