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Public Voucher For Language Services DS-3023 - Official Federal Forms

Public Voucher For Language Services Form. This is a national form and can be used in Visa US Department Of State .
 Fillable pdf Last Modified 4/11/2007
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U. S. Department of State Voucher Number PUBLIC VOUCHER FOR LANGUAGE SERVICES Title: Conference Interpreter Seminar Interpreter Consecutive Interpreter ELO/COURT Testing and Screening Translating Services PERIOD OF SERVICE (mm-dd-yyyy) FROM TO Payee's Name and Bank Information NOTE: Submit all Address/Banking Information changes with voucher. Name (Last, First, MI.) SSN Bank Name Routing Number (ABA) Account Number Account Type (Savings) or (Checking) NUMBER OF DAYS OR WORDS Job Number Contract Number (BOA) Date Voucher Prepared (mm-dd-yyyy) Reviewer/Typist/Others Home Phone Number NATURE OF SERVICES OR ARTICLES (Enter description and other information) UNIT PRICE COST PER AMOUNT (Dollars and Cents) FOR INTERPRETERS ONLY: Please specify Agency or Program for which work was performed I certify that the above charges are correct to the best of my knowledge; that I have not received payment or credit for them; that the services were rendered as stated, solely by the undersigned, and in accordance with the highest professional standards. Payee's Signature TOTAL PAYMENT: (check one) (Check one) Final Partial of *Payment due within 30 days* PAYEE MUST NOT USE THE SPACE BELOW Date Goods/Services Received/Accepted (mm-dd-yyyy) I certify this account is correct and proper for payment. Office of Language Services SA-1, 14th Floor 2401 E Street, NW Washington, DC 20522 Signature of Authorizing/Receiving Official Printed Name of Receiving Official Phone Number ACCOUNTING CLASSIFICATION Paid By: Check Number On (Name of Bank) Dated (mm-dd-yyyy) PRIVACY ACT STATEMENT This information requested on this form is required under the provisions of 31 U.S.C. 82b AND 82c, for the purpose of disbursing Federal money. The information requested is to identify the particular creditor and the amount to be paid. Failure to furnish this information will hinder discharge of the payment obligation. DS-3023 02-2006 Original - RM - Action Office Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com U. S. Department of State Voucher Number PUBLIC VOUCHER FOR LANGUAGE SERVICES Title: Conference Interpreter Seminar Interpreter Consecutive Interpreter ELO/COURT Testing and Screening Translating Services PERIOD OF SERVICE (mm-dd-yyyy) FROM TO Payee's Name and Bank Information NOTE: Submit all Address/Banking Information changes with voucher. Name (Last, First, MI.) SSN Bank Name Routing Number (ABA) Account Number Account Type (Savings) or (Checking) NUMBER OF DAYS OR WORDS Job Number Contract Number (BOA) Date Voucher Prepared (mm-dd-yyyy) Reviewer/Typist/Others Home Phone Number NATURE OF SERVICES OR ARTICLES (Enter description and other information) UNIT PRICE COST PER AMOUNT (Dollars and Cents) FOR INTERPRETERS ONLY: Please specify Agency or Program for which work was performed I certify that the above charges are correct to the best of my knowledge; that I have not received payment or credit for them; that the services were rendered as stated, solely by the undersigned, and in accordance with the highest professional standards. Payee's Signature TOTAL PAYMENT: (check one) (Check one) Final Partial of *Payment due within 30 days* PAYEE MUST NOT USE THE SPACE BELOW Date Goods/Services Received/Accepted (mm-dd-yyyy) I certify this account is correct and proper for payment. Office of Language Services SA-1, 14th Floor 2401 E Street, NW Washington, DC 20522 Signature of Authorizing/Receiving Official Printed Name of Receiving Official Phone Number ACCOUNTING CLASSIFICATION Paid By: Check Number On (Name of Bank) Dated (mm-dd-yyyy) PRIVACY ACT STATEMENT This information requested on this form is required under the provisions of 31 U.S.C. 82b AND 82c, for the purpose of disbursing Federal money. The information requested is to identify the particular creditor and the amount to be paid. Failure to furnish this information will hinder discharge of the payment obligation. DS-3023 Copy 1 - A/OPR/LS Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com U. S. Department of State Voucher Number PUBLIC VOUCHER FOR LANGUAGE SERVICES Title: Conference Interpreter Seminar Interpreter Consecutive Interpreter ELO/COURT Testing and Screening Translating Services PERIOD OF SERVICE (mm-dd-yyyy) FROM TO Payee's Name and Bank Information NOTE: Submit all Address/Banking Information changes with voucher. Name (Last, First, MI.) SSN Bank Name Routing Number (ABA) Account Number Account Type (Savings) or (Checking) NUMBER OF DAYS OR WORDS Job Number Contract Number (BOA) Date Voucher Prepared (mm-dd-yyyy) Reviewer/Typist/Others Home Phone Number NATURE OF SERVICES OR ARTICLES (Enter description and other information) UNIT PRICE COST PER AMOUNT (Dollars and Cents) FOR INTERPRETERS ONLY: Please specify Agency or Program for which work was performed I certify that the above charges are correct to the best of my knowledge; that I have not received payment or credit for them; that the services were rendered as stated, solely by the undersigned, and in accordance with the highest professional standards. Payee's Signature TOTAL PAYMENT: (check one) (Check one) Final Partial of *Payment due within 30 days* PAYEE MUST NOT USE THE SPACE BELOW Date Goods/Services Received/Accepted (mm-dd-yyyy) I certify this account is correct and proper for payment. Office of Language Services SA-1, 14th Floor 2401 E Street, NW Washington, DC 20522 Signature of Authorizing/Receiving Official Printed Name of Receiving Official Phone Number ACCOUNTING CLASSIFICATION Paid By: Check Number On (Name of Bank) Dated (mm-dd-yyyy) PRIVACY ACT STATEMENT This information requested on this form is required under the provisions of 31 U.S.C. 82b AND 82c, for the purpose of disbursing Federal money. The information requested is to identify the particular creditor and the amount to be paid. Failure to furnish this information will hinder discharge of the payment obligation. DS-3023 Copy 2 - Contractor Copy Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com
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