FORM C-13 (REV. 4/09)
STATE OF ILLINOIS
Name and Location of State Agency or Institution
2. Taxpayer Identification Number
3. Vendor or Payee
LAST NAME FIRST NAME MIDDLE INITIAL
OR BUSINESS NAME
1. Comptroller 5. Agency
2. Agency 6. Agency
3. Agency 7. Retained by
4. Remittance Copy Vendor
4. Voucher No.
5. Voucher Date
6. Appropriation Account Code
7. Invoice Number
8. Invoice Date
10. Indicate Beginning and Ending Date of Service and GAAP Code. Give Complete Description
of Articles/Services Rendered or Attach Itemized Vendor Invoice
11. Quantity 12. Units 13. Unit Price 14. Amount
18. Exp. Obj 19. Exp. Amount
20. CFDA No.
22. Obligation No.
23 . Payment Amount
24. Total Payment Amount21. Total Exp.
25. For Agency Use Only
Approved for Payment
Head of Unit or Authorized Agent
Date Agency Head (Signature)
Certification of Receiving Agency
I certify that the goods or services specified on this voucher were for the use of this
agency and that the expenditure for such goods or services was authorized and lawful-
ly incurred, that such goods or services meet all the required standards set forth in the
purchase agreement or contract to which this voucher relates; and that the amount
shown on this voucher is correct and approved for payment. If applicable, the reporting
requirements of section 5.1 of the Governor’s Office of Management and Budget Act
have been met.
Disposition of Copies
PAYMENT OF INTEREST MAY BE
AVAILABLE IF THE STATE FAILS
TO COMPLY WITH THE STATE
PROMPT PAYMENT ACT, 30 ILCS 540.