HTML Preview Blank Invoice Receipt Certification page number 1.
INVOICE - RECEIPT CERTIFICATION (See Completion Instructions on Reverse)
1. PURCHASE ORDER NUMBER 3. DATE GOODS RECEIVED/ACCEPTED/ 4. DATE INVOICE RECEIVED
2. TYPE SHIPMENT (Check One)
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.
LINE
ITEM
P.O.
LINE
ITEM
NO.
DESCRIPTION
QUANTITY/
UNIT ISSUE
DOLLAR AMOUNT DESCRIPTION
QUANTITY/
UNIT ISSUE
DOLLAR AMOUNT
NO.
11
+ Non-Merchandise Charge
12
+ Freight
13
+ Federal Excise Tax
14
+ State or Local Tax
15
Sub-Total
16
- Trade-In
17
- Discount
18
- Credit
19
TOTAL $
20. RECEIPT EXCEPTION
AUTHORIZED OFFICIAL
25. Attach invoice and mail to: (Use of Window Envelope is Optional)
21. ADDRESS
22. SIGNATURE
23. DATE
FTS
and Number)
COMM
FORM AD 838-B USDA (Revised 2/91)
24. PHONE (Area Code
USDA, Office of Finance and Management
National Finance Center
P.O. Box 60075
New Orleans, Louisiana 70160
Clear Form
0.00
0.00