This form i
s
doctors, etc.
where invo
i
where Purc
h
I, _______
_
I, _______
_
(Signatu
r
I certify th
a
chase orde
r
PAY TO:
LAST 4 S
S
FED ID#:
ADDRES
S
ITEMIZATI
O
___________
___________
DATE NE
E
CHARGE
ACCOUN
T
ACCOUN
T
s
to be used
f
, for membe
r
i
ces or state
m
h
ase Orders h
a
_
________
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(Signature
o
_
_________
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e of Supe
vi
s
a
t this paym
r
had previo
u
_____
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S
#/
____
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(Must
a
S
: _____
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_____
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O
N, DETAIL
O
____________
____________
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DED: ___
_
TO ACCO
U
T
CODE#:
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T
CODE#:
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f
or the paym
e
r
ships, dues
a
m
ents are n
o
a
ve been iss
u
_
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o
f Claimant)
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s
or, Dean or
V
ent does no
t
u
sly been is
s
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a
ttach W-9 if
n
_
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________
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O
R PURPOS
E
_____________
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U
NT NAM
E
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e
nt of profes
s
a
nd cash ad
v
o
t normally
ed by the Pu
r
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c
V
-Pres)
I
n
t
represent a
s
ued throug
h
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n
ew vendor)
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E
: ___
_______
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E
: ________
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Re
q
s
ional servic
e
v
ances, for p
a
issued by t
h
r
chasing Dep
a
r
equest that
c
ertify that this
n
case of mate
r
payment fo
r
h
the Purch
a
_
________
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________
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A
_
_______
A
q
uest fo
r
Da
t
e
s such as sp
e
a
yments to i
n
h
e payee. T
h
a
rtment in ad
v
the followi
n
material or se
r
r
ial, receipts f
o
r
material o
r
a
sing Depart
m
_
_________
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_
________
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_________
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_
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SELECT O
N
_
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A
MOUNT
$
A
MOUNT
$
TOTAL:
$
r
Direct
a
te: _______
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e
akers, musi
c
n
dividual em
p
h
is form sho
u
d
vance of co
m
n
g payment
b
rvice has been
o
r such
are att
a
r
service up
o
m
ent.
_
________
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_
_________
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________
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________
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___________
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N
E: MA
I
_
________
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$
________
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$
________
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$
________
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Payme
n
__
________
_
c
al organizati
p
loyees or ot
u
ld NOT be
u
m
mitment.
b
e made.
n
received upo
n
a
ched.
o
n which a
p
_
_________
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_
________
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_________
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_________
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____________
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___________
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___________
I
L PIC
K
_
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_
_________
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_
_________
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_________
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n
t
_
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ons,
t
hers
u
sed
n
payment
p
u
r
-
_
_
_
__
_
_
_
_
_
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__
____
____
K
UP
_
___
_
___
_
___
_
___