Invoice Number:
Date:
Order Number:
Company:
Address:
State: Zip:
Phone:
Fax:
Contact Name:
LOWER ALLOWAYS CREEK TOWNSHIP
PO Box 157 501 LOCUST ISLAND ROAD
HANCOCK'S BRIDGE, NEW JERSEY 08038
Phone: 856-935-1549
Fax: 856-935-1675
Address:
Purchase Order #
Vender #
CITY:
TIN: 22-2022400
APPROPRIATION ACCOUNT CHARGED
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____________________________________
____________________________________
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PAYMENT RECORD
Amount Paid:
Date:
Check No.
Delivery Slips Rendered and Checked.
.................................................................................................................................................
(Date) (Signature)
I, having knowledge of the facts, certify that the material and supplies have been received or the services
rendered; said certification being based on signed delivery slips or other reasonable procedures.
................................................................................................................................................
(Date) (Signature)
The above claim was approved
and ordered paid.
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(Date) (Clerk)
Account Code
Date of delivery
or service
Description of goods or service rendered, Itemize fully Quantity Unit Price
Total
Sub-total
Total
Claimant's Certification & Declaration
I do solemnly declare and certify under penalties of the LAW that the bill within is in all its particulars;
that the articles have been furnished or services rendered as stated therein; that no bonus has been given or
received by any person or persons within the knowledge of this claimant in connection with the above claim;
that the amount charged is a reasonable one.
........................................................................................................................................................................................................................................................
(Date) (Signature) (Official Position)
This certification must be signed by Vender before payment can be rendered.
Approved for payment by the LAC TOWNSHIP Committee Member (s) who have signed below:
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