Usda Invoice Template - Receipt Certification
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1INVOICE - RECEIPT CERTIFICATION (See Completion Instructions on Reverse)
1. PURCHASE ORDER NUMBER
3. DATE GOODS RECEIVED/ACCEPTED/
4. DATE INVOICE RECEIVED
(Check One)
2. TYPE SHIPMENT
SERVICE PERIOD END DATE
MONTH
DAY
YEAR
MONTH
DAY
YEAR
43 --
PARTIAL
COMPLETE
5. VENDOR INVOICE NUMBER
6. VENDOR NAME
I certify the items billed were received, inspected, and accepted as complying with this order except as noted below.
Bill amounts are to be charged to corresponding line items on purchase order as follows:
7
8
9
10
7
8
9
10
P.O.
P.O.
LINE
DESCRIPTION
DOLLAR AMOUNT
LINE
DESCRIPTION
DOLLAR AMOUNT
QUANTITY/
QUANTITY/
ITEM
ITEM
UNIT ISSUE
UNIT ISSUE
NO.
NO.
11
+ Non-Merchandise Charge
12
+ Freight
13
+ Federal Excise Tax
14
+ State or Local Tax
15
0.00
Sub-Total
16
- Trade-In
17
- Discount
18
- Credit
19
TOTAL $
0.00
20. RECEIPT EXCEPTION
AUTHORIZED OFFICIAL
25. Attach invoice and mail to: (Use of Window Envelope is Optional)
21. ADDRESS
USDA, Office of Finance and Management
National Finance Center
22. SIGNATURE
P.O. Box 60075
New Orleans, Louisiana 70160
23. DATE
(Area Code
24. PHONE
FTS
and Number)
COMM
FORM AD 838-B USDA (Revised 2/91)
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