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Town of Southold, New York - Payment Voucher
Entered by
Vendor NameVendor Address
Audit Date
Vendor Telephone Number
Town Clerk
Vendor Contact
InvoiceInvoice Invoice NetPurchase Order
NumberDateTotalDiscountAmount ClaimedNumberDescription of Goods or ServicesGeneral Ledger Fund and Account Number
Payee CertificationDepartment Certification
The undersigned (Claimant) (Acting on behalf of the above named claimant)I hereby certify that the materials above specified have been received by me
does hereby certify that the foregoing claim is true and correct, that no part hasin good condition without substitution, the services properly
been paid, except as therein stated, that the balance therein stated is actuallyperformed and that the quantities thereof have been verified with the exceptions
due and owing, and that taxes from which the Town is exempt are excluded.or discrepancies noted, and payment is approved.
Signature_________________________ Title ___________________________
Signature____________________________________________
Company Name Date___________________ Title
Date _________________