Voucher Number

¹ Originating Agency (limit to 30 spaces)

Orig. Agency Code

Interest Eligible (Y/N)

² P-Contract

Payment Date (MM/DD/YY)

OSC Use Only	Liability Date (MM/DD/YY)

³ Payee ID

Additional

Zip Code

Route

Payee Amount

MIR Date (MM/DD/YY)

 Payee Name (limit to 30 spaces)

IRS Code

IRS Amount

Payee Name (limit to 30 spaces)

Stat. Type

Statistic

Indicator-Dept.

Indicator-Statewide

Address (limit to 30 spaces)

 Ref/Inv. No. (Limit to 20 spaces)

Address (limit to 30 spaces)

Ref/Inv. Date (MM/DD/YY)

City (Limit to 20 spaces) (Limit to 2 spaces)(

State

Zip Code

6 Purchase Order No. and Date	Description of Material/Service

If items are too numerous to be incorporated into the block below,

use Form AC 93 and carry total forward.	Quantity	Unit	Price	Amount
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

 Payee Certification

I certify that the above bill is just, true and correct; that no part thereof has been paid except as stated and that

the balance is actually due and owing, and that taxes from which the State is exempt are excluded.

Payee’s Signature in Ink Title

Date Name of Company	Total

$0.00
Discount %
-$0.00
Net	$0.00
For Agency Use Only	State Comptroller’s Pre-Audit
Merchandise Received

Date

Page No.

By	I certify that this voucher is correct and just, and payment is approved, and the goods or services rendered or furnished are for use in the performance of the official functions and duties of this agency.

Authorized Signature in Ink

Date Title

Certified

for payment of

NET amount

By

Verified

Audited

Special Approval

(as Required)
Expenditure	Liquidation
Cost Center Code	Object	Accum	Amount	Orig. Agency	PO/Contract	Line	F/P
Dept	Cost Center Unit	Var	Yr
Dept	Statewide
Distribution: Original to OSC with Copy to Agency/Department and Payee	Check if Continuation form is attached.

Above Form MUST print on one page

NOTICE TO VENDORS OF SALES TAX EXEMPTION

This sheet may be retained by vendor and can be presented as proof of exemption from New York State and local sales taxes.

INSTRUCTIONS TO VENDORS PREPARING VOUCHERS

The numbered paragraphs below refer to the numbered blocks on the face of this form, which are to be completed.

Notice to vendors: Do not complete any blocks other than the following.

Originating Agency:

Insert name of State Department, Agency or institution being billed, as shown at the top of the Purchase Order.

P-Contract:

Enter here the P-Contract Number, if any, under which the purchase is made, e.g. P010966. Do not use hyphens or spaces.

NOTE: TO AVOID PROBLEMS WITH IRS, FOLLOW INSTRUCTIONS FOR BLOCKS 3 AND 4 CAREFULLY.

Payee I.D./Additional/Zip Code:

Enter your Federal Employer Identification Number (EIN). If you do not have an EIN, enter your Social Security Number. Do not use hyphens or spaces.

If you were assigned a Payee Additional Code by New York State, enter this in the box marked ‘Additional’. Enter your nine position ‘Zip+4’ in the adjacent block only if you have been assigned an Additional Code.

Payee Name and Address:

For individuals or sole proprietors, enter your name (exactly as it appears on your Social Security card) in the first Payee Name block. If there is a business name or DBA, Enter that information in the second Payee Name block.

Corporations, partnerships and tax exempt organizations should enter the name of the entity (exactly as registered with the Federal government) that corresponds to the EIN entered in Block 3.

Enter your proper mailing address conforming to U.S. Postal Standards. Include either your five-position zip code or your Zip+4 in your address.

Ref./Inv. No.:

Enter a reference number, invoice number, or other information. This information WILL APPEAR ON THE CHECK STUB and will identify the payment. Do not exceed 20 characters including letters, numbers, spaces, commas, etc. The check stub issued to you will contain the information you furnished in this block, and may be compared to this copy of the voucher, which you will detach and keep. Enter the corresponding reference/invoice date in the block below the Ref./Inv. No. block.

Description of Material/Service:

Enter all pertinent information required by the specific column headings. Extend calculations into “Amount” column.

VENDOR’S OPTION:

Any company that has its own invoice or bill form may refer to it by number or other identification in the Ref./Inv. No. block. In addition, write “See Invoice Attached” in the description block, and show the total in the “Amount” column. Attach invoices in duplicate to this voucher.

Payee Certification:

Clearly indicate the title of the person signing for the payee, e.g., sole owner, partner, treasurer, bookkeeper, billing clerk, etc.

Either print this form and fill-in manually or enter information in highlighted fields. When entering information into form fields, do not allow the page to break. Form and all information MUST print on one page.

For additional instructions on completion of this form see page 2.

To remove balloon comments from view go to TOOLS OPTIONS TRACK CHANGES under Balloons Section by the "Use Balloons in Print and Web Layout" select “Never”.

Quantity and Price MUST have input data for the amount field to calculate. Use the TAB key to move from field to field. The Net field will calculate and deduct the discount if the preparer enters a value and tabs out of the Discount field.

REVIEW ALL DATA ENTERED AND TOTALS FOR ACCURACY.

If a discount is to be applied to the total amount of the voucher, it MUST be entered as a DECIMAL. (ex. Enter 7% as .07)

AC92 (Rev. 6/94)

State

Of

New York

See instructions before completing

Standard Voucher

State of New York Travel Voucher

Voucher Preparer

2016-06-07

Administrator

NYS OSC