Free 12537.xls - Indiana

This page number

O F

Total number of pages

Requisition number Purchase Order number

Date of requisition

REPORT OF PARTIAL DELIVERY
State Form 12537 (R6 / 1-08) Approved by Auditor of State, 2008 Approved by State Board of Accounts, 2008
RECYCLED PAPER Purchase Order date

Required delivery date

This is the

______

partial delivery reported on this order.

I.D.O.A. identification number

Fund

Account Program

Budget Reference Department

Federal I.D. number Name & address of vendor Reporting Code (1099)

Business Unit

Name of requesting Business Unit / Approp. name

INSTRUCTIONS:
Delivered to:

Use this form only for reporting partial deliveries on a Purchase Order. Use the receiving room copy (part 4) of the Purchase Order for reporting the final delivery on the order. Forward this report without delay to:

AUDITOR OF STATE 200 W WASHINGTON ST RM 144 INDIANAPOLIS, IN 46204
This document authorizes the Auditor to pay the claim.

F.O.B. DESTINATION unless otherwise stated below
Contract Line Item No.

NOTICE: No price corrections will be permitted after issuance of this Purchase Order.

UNIT

QUANTITY RECEIVED

ARTICLE and DESCRIPTION

UNIT PRICE

AMOUNT

Please pay this amount:
REQUESTING BUSINESS UNIT'S CERTIFICATION OF RECEIPT AND COMPLIANCE
Confirmation of Receipt
I certify that the items listed above were received and checked by me on the date indicated. All commodities appeared to conform to specifications and showed no patent defects, except as otherwise noted. Signature of Receiver Typed / printed name Date signed

Approval for Payment
I certify that the vendor has performed in accordance with the terms and contract obligations pertaining to the Purchase Order, and I hereby athorize and approve payment of appropriate claims. Authorized Signature for Business Unit Typed / printed name Date signed