POST OFFICE VALIDATION
AUTHORIZED AGENCY SIGNATURE
I hereby certify that the items listed above are for the sole use by thisagency for business purposes only.
I hereby certify that the items or services listed above were received by me on this date, and were purchased for business purposes only.
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