Free 11649.xls - Indiana

SPECIAL DISBURSING OFFICER REIMBURSEMENT VOUCHER
State Form 11649 (R2 / 1-08) Approved by Auditor of State, 2008 Approved by State Board of Accounts, 2008
INSTRUCTIONS: Business Units will complete this form and send the first two (2) copies to the Department of Administration, Procurement Division, along with the originals of all supporting vendor invoices. Please use additional sheets of paper for vendors names and amounts if necessary.

Business Unit Name Document Number Name of Special Disbursing Officer

Business Unit Number Local Purchase Number Date (Month,Day,Year)

I certify that the attached claim of the vendors named hereon are just and legal charges against the State of Indiana; that the articles and services named thereon were contracted for in accordance with the authority granted in the above-numbered Authority for local Purchases; and that the said articles and services have been settled in full from the moneys advanced to me as a Special Disbursing Officer under said Authority For Local Purchases. Special Disbursing Officer Factor Number Signature of Disbursing Officer

AMOUNT

FUND

ACCOUNT

BUDGET REFERENCE

PROGRAM

DEPARTMENT

Gross Amount of this Voucher White (top) Copy and Pink Copy-Department of Administration,Procurement Division; Canary Copy - Business Unit's Files