REGISTRATION, INVOICE & VOUCHER CERTIFICATION FORM VENDOR CLAIMANT'S CERTIFICATION AND DECLARATION I do solemnly declare and certify under the penalties of the Law that the bill/invoice statement is correct in all its particulars; that the materials have been furnished or services rendered as stated herein; that no bonus has been given or received by any person or persons within the knowledge of this claimant in connection with above claim; that the amount therein stated is justly due and owing; and that the amount charged is a reasonable one. 1-01-12 26-1564972 Laurie A. Barton Owner/Instructor Date Federal I.D. # Signature Official Position
NAME OF COURSE : LOCATION: CERTIFICATION BY RECEIVING AGENCY CERTIFICATION BY APPROVAL OFFICIAL______________________________________________________________________________ I, having knowledge of the facts, certify and declare that I certify and declare that this bill/invoice statement is correct, and that the materials have been received or the services sufficient funds are available to satisfy this claim. The payment shall be rendered and are in compliance with the specifications chargeable to: If PO is REQUIRED, THEN THE PO# MUST BE NOTED! or other requirements, and said certification is based on signed delivery slips or other reasonable procedures, or ______________________________________________________________________ verifiable information. Appropriation Account(s) Charged P.O. # - MANDATORY Amount(s): $ ________ Signature ______________________________________ Signature ________________________________ Title ___________________________ Date _____________ Title (CFO, Finance Director) _________________________ Date: |