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<br />PURCHASE VOl 'ER <br />ARK.TEX COUNCIL OF GvvERNMENTS <br /> <br />1.f] Pay to: (Name, Adr4."~s, City, State, Zip) <br />(City Cou nty' 'bchoo I ect...) <br /> <br />~ <br /> <br />... .". <br /> <br />. 't' ,,, <br /> <br />P.O. Box 5307 <br />Texarkana, TX 75505.5307 <br />(Submh In Triplicate) <br /> <br />~ Contrad or Grant No: <br /> <br />:EJ Vendor No: <br /> <br />d. Delivery Date/Period and Description ,of Articles or Services Provided ,': :>t. <br />Payment Period: <br />~.JJ.2i. to .iJJ.J..22 <br /> <br />." <br /> <br />'. f. ':':":::::},:)::. <:}:", ::},..:" : ,:, ::,.' . ":'.:,:::- '.::, ..." ',.,:,:" <br /> <br />Amount Due <br /> <br />For reimbursement for the ectlvltles under the <br />Ark-Tex CouncIl of Governments RegIonel SolId <br />Waste Management Plan Pass Through Grants as <br />funded by the Texas Natural Resources Conservetlon <br />CommIssion <br /> <br />Cummuletive expenditures to dete <br />Less on Prior RequisItion <br />Due this voucher <br /> <br />2,500.00 <br />-0- <br />2,500.00 <br /> <br />$2,500.00 <br /> <br />Contrect emount <br />Expended to dete <br />Balance remeIning <br /> <br />$7,500.00 <br />2,500.00 <br />$5,000.00 <br /> <br />sample <br /> <br />o c er <br /> <br />JJ I cenify that the above services/goods were <br />renderedlrtetived, and that they correspond in <br />.very way whh the c:ontrad under which they were <br />procured and that the Invoice is true and unpaid. <br />A TCOG Date Approved for Payment: <br />APPROVAL <br />FOR PAYMENT <br />Signature: <br /> <br />,.' .:: ,,,:. . . .,,, <br />~:'VOUCHERTOTAL":: 4"": $2,500.00 <br />S~nature - Vendor Representative: Telephone No: <br /> <br />Tnle: <br /> <br />Date: <br /> <br />ATCOG DISTRIBUTION ACCOUNT <br /> <br />AMOUNT <br /> <br />Title: <br />Envlronmentel Resources Plenner <br />Signature: <br /> <br />Tnle: <br />Director, Reg i one I' Serv ices <br /> <br />Vendor No: <br /> <br />Coded by: <br />. <br /> <br />Check No: <br /> <br />Date: <br /> <br />Amount: <br />