Claim For Payment {AC3253-S}

AC3253-S (Effective 1/12) State of New York CLAIM FOR PAYMENT Vendor Information Vendor Identification Number City Invoice Number State Zip Code Vendor Name Address Purchase Order No. and Date Description of Materials/Service Quantity Unit Price Amount Vendor Certification I certify that the above bill is just, true and correct; that no part thereof has been paid except as stated and that the balance is actually due and owing, and that taxes from which the State is exempt are excluded. Total Discount % Vendor's Signature in Ink Title Net Date Name of Company NYS Agency Information Vendor Identification Number Vendor Location ID Vendor Address Sequence Voucher ID Business Unit Name Bus. Unit Interest Eligible (Y/N) Contract ID Payment Date (MM) (DD) (YY) Liability Date (MM) (DD) (YY) Merch/Inv. Rec'd Date Agency Internal Use (MM) (DD) (YY) Withholding Class Withholding Amount Handling Code Payee Amount Invoice Number Invoice Date PeopleSoft Format Charge Lines (If Applicable) Business Unit Department Program Fund Account Budget Reference Project ID Activity Class Operating Unit Product Chartfield 1 - Accumulator Chartfield 2 - Agency Use Chartfield 3 Amount Legacy Format Charge Lines (If Applicable) Expenditures Dept Cost Center Var Yr. Object Accum Dept. Statewide Amount Orig.Agency PO/Contract Liquidation Line F/P Liability Date From Date TC Subledger Optional American LegalNet, Inc. www.FormsWorkFlow.com