| Caption on the SF 1034 |
Data to be inserted in the
block |
| 1. U.S.
Department, Bureau, or establishment and location |
Name and address of the
contracting office which issued the contract. |
| 2. Date voucher
prepared |
Date voucher submitted to the
designated billing office cited under the contract or order. |
| 3. Contract No.
and date |
Contract No. and, when
applicable, the Order No. and date as shown on the award
document. |
| 4. Requisition No.
and date |
Leave blank or fill-in in
accordance with the instructions in the contract. |
| 5. Voucher
No. |
Start with “1” and number
consecutively. A separate series of consecutive numbers must be
used beginning with “1” for each contract number or order number
(when applicable). Note: Insert the word “FINAL” if this is the
last voucher. |
| 6. Schedule No.;
paid by; date invoice received; discount terms; payee's account
No.; shipped from/to; weight; government B/L |
Leave all these blocks
blank. |
| 7. Payee's name
and address |
Name and address of contractor
as it appears on the contract. If the contract is assigned to a
bank, also show “CONTRACT ASSIGNED” below the name and address of
the contractor. |
| 8. Number and date
or order |
Leave blank. (See #3
above.) |
| 9. Date of
delivery or service |
The period for which the
incurred costs are being claimed (e.g., month and year; beginning
and ending date of services, etc.). |
| 10. Articles or
services |
Insert the following: “For
detail, see the total amount of the claim transferred from the
attached SF 1035, page X of X.” One space below this line, insert
the following: “COST REIMBURSABLE-PROVISIONAL PAYMENT.” |
| 11. Quantity; unit
price; (cost; per) |
Leave blank. |
| 12. Amount |
Insert the total amount
claimed from the last page of the SF 1035. |
| Payee must NOT use
the space below |
Do NOT write or type below
this line. |