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 American LegalNet, Inc. www.FormsWorkFlow.com