Claim For Payment
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Claim For Payment Form. This is a New York form and can be use in Appellate Division Appellate Courts.
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Tags: Claim For Payment, AC3253-S, New York Appellate Courts, Appellate Division
AC3253-S (Effective 1/12)
State
of
New York
CLAIM FOR PAYMENT
Vendor Information
Vendor Name
Vendor Identification Number
Address
City
Zip Code
State
Invoice Number
Purchase Order No. and Date
Description of Materials/Service
Unit
Quantity
Price
Amount
Vendor Certification
Total
I certify that the above bill is just, true and correct; that no part thereof has been paid except as stated and that the balance is
actually due and owing, and that taxes from which the State is exempt are excluded.
Discount %
Vendor's Signature in Ink
Title
Net
Date
Name of Company
NYS Agency Information
Vendor Identification Number
Voucher ID
Vendor Location ID
Vendor Address Sequence
Business Unit Name
Payment Date (MM)
(DD)
Withholding Class
Bus. Unit
(YY)
Liability Date
Withholding Amount
(MM)
Handling Code
(DD)
(YY)
Contract ID
Merch/Inv. Rec'd Date
(MM)
(DD)
(YY)
Agency Internal Use
Payee Amount
Invoice Number
Interest Eligible
(Y/N)
Invoice Date
PeopleSoft Format Charge Lines (If Applicable)
Business Unit
Department
Program
Fund
Account
Budget Reference
Project ID
Activity
Class
Operating Unit
Product
Chartfield 1 - Accumulator
Chartfield 2 - Agency Use
Chartfield 3
Amount
Legacy Format Charge Lines (If Applicable)
Expenditures
Dept
Cost Center
Liability Date
Var
Yr.
From Date
Object
TC
Liquidation
Accum
Dept.
Statewide
Subledger
Amount
Orig.Agency
PO/Contract
Line
F/P
Optional
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