Free 45636.FH11 - Indiana

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CLAIM VOUCHER -- FOOD STAMPS
State Form 45636 (R6 / 4-09) / IMP 2641B Approved by State Board of Accounts, 2002

INSTRUCTIONS: This agency is requesting disclosure of your Social Security number in accordance with IC 4-1-8-1. VENDOR INFORMATION
Document number Vendor name Address (number and street) Date (month, day, year) Agency name

AGENCY INFORMATION

Division of Family Resources, FSSA - IMPACT (FS)
Agency number

500
Social Security number or

0Federal I.D. number

0City, state and ZIP code

Vendor number

DATE

AMOUNT

FUND

OBJECT

AREA BELOW TO BE COMPLETED BY AGENCY CENTER LOAN / INV / NBR QTY

UNIT

DESCRIPTION

2250

572700

150000

NO

Name of participant

County number

Case number

Social Security number

SERVICE CODE 01

Services for:

Thru:
Prepared by: Date prepared (month, day, year) Telephone number

0.00 Mileage: Number of Miles ____________ X .10 = $ _______________
or $2.00 per day, whichever is higher $ _______________

02 03 04 05 07

Bus Tokens Gas Coupons Vehicle Expenses Clothing, Uniforms, and Shoes Training / Tuition / GED Fees / Books

$ $ $ $ $

(
Comments:

)
(Reason for request)

NOTE: Service Codes 01 through 10 cannot exceed $100.00 per month per participant, except training / tuition / GED fees which are not subject to this limit.

Division of Family Resources, FSSA I certify that this claim is correct and valid and is a proper charge against the State Agency, Fund and Center indicated.
Authorized Signature of Local Office Date signed (month, day, year)

GROSS AMOUNT: $

Furnished to: (Name of State Agency)

Pursuant to the provisions and penalties of IC 5-11-10-1, I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after allowing all just credits, and that no part of the same has been paid.
Signature of Vendor Date signed (month, day, year)

DISTRIBUTION: White - Return for payment with original invoice; Canary - Vendor copy; Pink - Case file