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)
Date: __________
Vendor’s Name: ________________________________________
V-Number: ______________________
Address: ________________________________________
________________________________________
________________________________________
Description of Service:
Date of Service ___________
Please include wire information below:
Beneficiary name ________________ Beneficiary Acct # ______________
Street Address ________________________________________________
City_______________ State __ Country______________ Zip code_______
Beneficiary Bank __________________ ABA/SWIFT # _________________
Street Address (if applicable)_________________________________________
City_______________ State __ Country______________ Zip code_______
Additional Instructions_________________________________________
 Please process payment prior to event and send wire confirmation to
______________________at Mail Code ________.
Charge to Index__________ Account ________.
Budget Manager Signature (required) ______________________________
Amount Due: _$_________________ (US Dollars)
Date Service Completed ________________
I certify that a Contract Agreement has been
completed and amount due is approved for payment.
Signature _________________________ Date ___________
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