Form BIA-4311
Revised 8/13
United States Department of the Interior
Indian Affairs
Receiving Report
1
To (Servicing Property and Finance Office):
Vendor:
Purchase Order Number/Contract Number/Interagency Agreement Number/
Charge Card Number:
Vendor Address:
Item Number
Description, Make, Model, and Serial Number or Services
Quantity
Cost
1
2
3
4
5
6
Process Payment against Purchase Order No.:
Line No.:
Line No.:
Line No.:
Partial: [ ]
Final: [ ]
Or, will be paid against government credit card:
Shipment:
Partial (list item numbers):
Final (list item numbers):
Date Received:
Name:
Title:
Signature:
Address:
Date Accepted:
Name:
Title:
Signature:
Address:
Item No.:
Reason:
Returned to Vendor
Date:
Method:
Item No.:
Reason:
Returned to Vendor
Date:
Method:
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
2
Additional room for item numbers and report of rejections
Item Number
Description, Make, Model, and Serial Number or Services
Quantity
Cost
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Item No.:
Reason:
Returned to Vendor
Date:
Method:
Item No.:
Reason:
Returned to Vendor
Date:
Method:
Item No.:
Reason:
Returned to Vendor
Date:
Method:
Item No.:
Reason:
Returned to Vendor
Date:
Method:
Item No.:
Reason:
Returned to Vendor
Date:
Method: