Fillable Form 1099: ESSEX COUNTY VOUCHER PERIOR YEAR __ (Monroe-Woodbury Central School District)

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Form 1099: ESSEX COUNTY VOUCHER PERIOR YEAR __ (Monroe-Woodbury Central School District)

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The Form 1099: ESSEX COUNTY VOUCHER PERIOR YEAR __ (Monroe-Woodbury Central School District) form is 2 pages long and contains:

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  • 21 check-boxes
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File type: PDF

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ENC
/
NO ENC
BATCH # INVOICE #
ACCT
GRP ACCT
AMOUNT
1099
VCHR #
INVOICE #
INVOICE DATE
DUE DATE
CASH ACCOUNT
SINGLE CHECK Y N
ACCOUNT GROUP
ACCOUNT
TASK
ACCOUNT
AMOUNT
AMT ALLOWED
1099 Y N (TITLE) (DATE)
VOUCHER #
DESCRIPTION
CHECK #
ESSEX COUNTY VOUCHER
FOR AUDITORS OFFICE USE ONLY
I HEREBY CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT, THAT THE SAID SERVICES WERE
RENDERED OR SUPPLIES FURNISHED AS STATED THEREIN, THAT NO PART OF THEREOF HAS BEEN PAID AND THAT
THE AMOUNT IS STATED ACCURATELY DUE AND OWING
DATE__________________________
NOTE: VOUCHER PACKET INCLUDES:
* Completed Voucher
*Original Invoice, Receipt or Packing Slips
*Payment Copy of Purchase Order
PERIOR YEAR __ __ / __ __
VENDOR OR PO #
VENDOR NAME AND ADDRESS
DESCRIPTION
APPROVED BY (DEPARTMENT HEAD) AUDITED BY DATE AUDITED
(PRINTED NAME) (SIGNATURE)
Do not alter Essex County Forms they have been designed to meet State and Federal requirements.
0.00
Total:
Contract number, Daily Log, & Progress Notes MUST be included.
VOUCHER
ESSEX COUNTY GOVERNMENT CENTER
100 COURT STREET
P.O. BOX 217
ELIZABETHTOWN, NY 12932
DATE_____________________
License #______________________
Contract #_____________________
PRESCHOOL SPECIAL EDUCATION
DATE INVOICE NUMBER QUANTITY DESC OF MATERIALS OR SERVICES UNIT PRICE AMOUNT
_________________ _____________________
Name of child MO/YR of Service
Initial Evaluation
Date Signed by Psychologist ______________
Name:________________________________
Credentials:____________________________
Supplemental Evaluation
________________ Date______________
SERVICES FREQUENCY
(EX. 3X60)
Center based Site __________________
Center based Tuition __________________
Center based Aide __________________
SEIT __________________
Related Services/Therapy
Physical Therapy __________________
Occupational Therapy ___________________
Speech Therapy ___________________
OTHER _________________ ___________________
CLAIMANT'S
NAME AND
ADDRESS
Do not alter Essex County Forms they have been designed to meet State and Federal requirements.
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Form 1099: ESSEX COUNTY VOUCHER PERIOR YEAR __ (Monroe-Woodbury Central School District)

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Completed 15 April 2021

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