Number of agency submitting batch (refer to agency codes table 3.2 for valid numbers)

5

BATCH NUMBER

NO. OF DOCUMENTS

BATCH AMOUNT

5

SUBMITTED BY (AGENCY NAME)Submitting agency's name

TELEPHONE NUMBER - BUSINESS OFFICE
Preparer's telephone number including area code

PAYEE

Payee's name

PAYEE LIST

For invoice listing - check box if payee list exists

PURCHASE ORDER NUMBER

Enter document type and purchase order number

Enter document type and requisition for reservation of funds, travel authorization number, or personal service agreement number

Total amount of attached document

Authorized agency signature. Must not be the same individual authorizing the expenditure document(s).

Please print the name of the individual that can answer specific questions regarding the batch

Current date in month-day-year format

Total amount of goods and/or services. This amount must equal the sum of the detail amounts in the coding section (block 25).

Date the agency receives invoice from the vendor in MM-DD-YYYY format. Refer to Section 1.6 for detailed instructions on completion of document date for various common invoice situations.

Date goods and/or services were received or rendered in MM-DD-YYYY format. If the billing is for a period of time (services, etc.) enter the ending date of the period. Refer to Section 1.7 for detailed instructions on completion of receipt date for various common invoice situations.

Reference original commitment document for commitment number. If this claim references a general reservation, the reservation number should be entered.

Refer to original commitment document for commitment type (PS, PO, RR, RL)

Agency number of appropriation charged with commitment. (refer to agency codes table 3.2 for valid numbers)

Indicate whether the obligated amount is being paid in full by the letter "F"; otherwise, leave blank. If fully liquidating a commitment, the "F" is placed in the header. If fully liquidating a line, place the "F" on that line.

Reportable type (Y-yes, N-no, T-town code)

List federal employer identification number, social security number, or town code, exception code, along with a 2 digit suffix number to identify location.

Payee's name and address

Check one; yes or no

Check one; yes or no.

One line of 52 characters to indicate e.g. (vendor invoice, client name, date, grant payment code) or other vendor identification information. This information will be printed on the generated check for the reconciliation of the vendor's accounts receivables.

Full description of goods or services completed.

Quantity of purchased units

Item's unit of measurement (e.g. box, case, package, pound)

Price of purchased unit

Number of units (x) purchase price for each item

Indicate whether specific commitment line item is being paid in full by the letter "F"; otherwise, leave blank. If fully liquidating the commitment, the "F" is placed in the header only.

Reference original commitment document's line number. Up to 99 lines may be listed for each document. For additional lines, use Expenditure Detail Coding Continuation, Form C0-957, and write "see attached" on last detail line of this document.

That portion of the committed amount that is being paid.

Number of agency charged for appropriation (refer to agency codes table 3.2 for valid numbers).

Fund & special ID (SID) related to the appropriation which is charged (refer to fund table 3.1 for valid funds).

Classification of expenditure disclosing the essential nature of the expenditure or actual items being purchased (refer to expense object table 3.4 for valid object numbers). The fifth position of object must be zero unless specifically approved by the Comptroller.

Four position function code used by agencies to further classify the committed amount.

Nine position activity code used by agencies to further classify the committed amount.

Field available to agencies for additional classification of commitment. This field will not be data entered centrally.

Current fiscal year. The higher side of the fiscal year must be used; for example, fiscal 97-98 should be coded as 1998. Leave blank for current fiscal year--system defaults to current fiscal year.

Submitting agency's name and address

Signature of person receiving goods or services rendered. This must not be the same individual authorizing the expenditure batch header.

Receiving report number - See receiving report form C0-16

Date goods or services were received or rendered. If the billing is for a period of time (services, etc.) enter the ending date of the period.

In month-day-year format.

City/state/zip

Name of shipping concern.

Note any exception.