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1 <br /> DOCUMENT ID <br /> THE COMMONWEALTH OF MASSACHI <br /> E�EPT R/ORG NUMBER PV DATE ACCTG PRD BUD FY _ _ _ COMPTROLLER'S DIVISION <br /> r� _ <br /> 3C0d0 $ oPAYMENT VOUCHER INPUT FOF <br /> SCH PAY DATE OFF LIAB ACCTVENDOR'S CERTIFICATION: <br /> r (certify that the goods were shipped or the DEPARTMENT/ORGANIZATION NAME <br /> service rendered as set tort below. `` _ <br /> �/� E/7 U. k / <br /> ...... <br /> :.. . .................... .... <br /> � -� VENDOR NAME AND ADDRESS <br /> DOCUMENT TOTAL: rDEPT VENDOR INVOICE NUMBER FVR CODE: i "W t/ �r2CaS vre!^ <br /> rW� bOi- J7S oav EMP Ala sk�e�, 144 Uoz ye <br /> REFERENCED ORDER LINE QUANTITY DESCRIPTION <br /> UNIT PRICE =MOL <br /> I <br /> 7 I <br /> ke,1-n aY3eme1-7E' <br /> � I <br /> � I <br /> I <br /> w I <br /> t7 I <br /> Z I <br /> I <br /> N I <br /> I <br /> r� I <br /> X I <br /> m I <br /> O I <br /> d I <br /> U5 <br /> I <br /> s I <br /> I <br /> Z <br /> REFERENCED ORDER <br /> I <br /> W <br /> tTRAN DEPT R/ORG NUMBER LINE DEPT APPROP SUB ORG S/ORG OBJ S/OBJ PROG TYa61F(A)e 3600 Qr �� E ����'- 0(cpVPROJ/CL/GF <br /> 11 3 <br /> FUND BS ACCT DEPT VENDOR INVOICE NUMBER: DESCRIPTION: <br /> DISC DATES OF SERVICE QUANTITY AMOUNT: I/D P/F <br /> TO <br /> TO THE COMPTROLLER OF THE COMMONWEALTH OF MASSACHUSETTS: <br /> I hereby certify under the penalties of perjury that all laws of the Commonwealth governing disbursements of <br /> public funds and the regulations thereof have been complied with and observed. <br /> PREPARED BY: TITLE: fit ti� •- � DATE: INSTRUCTIONS TO VENDC <br /> APPROVED BY: TITLE: FILL IN SHADED AREAS <br /> DATE: DIRECT INQUIRIES TO <br /> ENTERED BY: TITLE: STATE ORGANIZATION <br /> DATE: __ RETAIN GREEN COPY <br />