POSTAL SERVICES TRANSACTION AUTHORIZATION
CO-924 REV. 11/03 (Stock No. 478-01)
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
ACCOUNTS PAYABLE DIVISION
INSTRUCTIONS
1. Please print or type.
2. This form must be validated by the Post Office in the space provided.
3. Itemize number purchased, total cost of each unit, and total cost of all goods or services purchased. (Attached additional sheets if necessary).
4. This form must be completed to document receipt of postal goods or services. Attach Form CO-924 to the original voucher.
POST OFFICE VALIDATION
DATE
DATE
DATE
TITLE
TITLE
AUTHORIZED AGENCY SIGNATURE
I hereby certify that the items listed above are for the sole use by this
agency for business purposes only.
AGENCY CERTIFICATION
I hereby certify that the items or services listed above were received by me on this date, and were purchased for business purposes only.
COURIER'S SIGNATURE
SIGNATURE - REQUESTER
I hereby certify that the items detailed above are necessary to carry out the functions of this department
COMBINE TOTALS OF SECTIONS A, B AND C AND POST GRAND TOTAL AT RIGHT
TOTAL COST
TOTAL COST
TOTAL COST
(C)
(A)
(B)
REQUESTING DEPARTMENT
DATE
STAMPS
OTHER SERVICES
MONEY ORDERS
AMOUNT
AMOUNT
AMOUNT
SERVICE CHARGE
SERVICE CHARGE
SERVICE CHARGE
PAYEE
ADDRESS
PAYEE
ADDRESS
PAYEE
ADDRESS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

POST OFFICE VALIDATION

 
 
 

DATE

DATE

DATE

TITLE

TITLE

AUTHORIZED AGENCY SIGNATURE

I hereby certify that the items listed above are for the sole use by this
agency for business purposes only.

AGENCY CERTIFICATION

I hereby certify that the items or services listed above were received by me on this date, and were purchased for business purposes only.

COURIER'S SIGNATURE

SIGNATURE - REQUESTER

I hereby certify that the items detailed above are necessary to carry out the functions of this department

COMBINE TOTALS OF SECTIONS A, B AND C AND POST GRAND TOTAL AT RIGHT

 

TOTAL COST

TOTAL COST

TOTAL COST

(C)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

(A)

(B)

REQUESTING DEPARTMENT

 
 
 
 

DATE

STAMPS

OTHER SERVICES

MONEY ORDERS

AMOUNT

AMOUNT

AMOUNT

 

SERVICE CHARGE

SERVICE CHARGE

SERVICE CHARGE

PAYEE

ADDRESS

PAYEE

ADDRESS

PAYEE

ADDRESS