Standard Form No. 1034a
7 GAO 5000
1034-209-02

PUBLIC VOUCHER FOR PURCHASES AND
SERVICES OTHER THAN PERSONAL

64117 3235

U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION		DATE VOUCHER PREPARED		VOUCHER NUMBER
ARMY - OFFICE OF THE SURGEON GENERAL		June 22, 1964		54
		CONTRACT NUMBER AND DATE		PAID BY
		DA-49-007-MD-1024
		REQUISITION NUMBER AND DATE
PAYEE'S NAME AND ADDRESS	WASHINGTON UNIVERSITY Lindell & Skinker Boulevards St. Louis, Missouri 63130			DATE INVOICE RECEIVED
				DISCOUNT TERMS
				PAYEE'S ACCOUNT NUMBER
				23 2464 3235 64117
SHIPPED FROM		TO		WEIGHT
				GOVERNMENT B/L NUMBER
NUMBER AND DATE OF ORDER	DATE OF DELIVERY OR SERVICE	ARTICLES OR SERVICES (Enter description, item number of contract or Federal supply schedule, and other information deemed necessary)	QUAN- TITY	UNIT PRICE COST PER	AMOUNT
	May 1, May 31, 1964	Direct Salaries Direct Materials Equipment Other Direct Costs Overhead			$ 292.00 309.80 211.68 124.70 128.48
(Use continuation sheet(s) if necessary)		(Payee must NOT use the space below)		TOTAL	$ 1,066.66
PAYMENT:				DIFFERENCES
COMPLETE
PARTIAL
FINAL
PROGRESS
ADVANCE
Amount verified; correct for (Signature or initials)
MEMORANDUM
ACCOUNTING CLASSIFICATION (Appropriation symbol must be shown; other classification optional)
PAID BY	CHECK NUMBER	ON TREASURER OF THE UNITED STATES	CHECK NUMBER	ON (Name of bank)
	CASH	DATE
	$

☆ U.S. GOVERNMENT PRINTING OFFICE: 1963-O-675800

Source: https://www.industrydocuments.ucsf.edu/docs/pxlg0227