AC 92 (Rev. 6/94) SEE INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING STATE STANDARD VOUCHER OF NEW YORK Originating Agency 1 Payment Date Orig. Agency Code / 3 2 P-Contract Interest Eligible (Y/N) Liability Date - OSC Use Only (MM) (DD) (YY) Voucher No. (MM) (DD) (YY) / / Payee ID Additional Zip Code Route / Payee Amount MIR Date (MM) (DD) (YY) / 4 Payee Name (Limit to 30 spaces) IRS Code Payee Name (Limit to 30 spaces) Stat. Type Statistic Address (Limit to 30 spaces) 5 Ref/inv. No. (Limit to 20 spaces) Address (Limit to 30 spaces) Ref/Inv. Date / IRS Amount Indicator-Dept. (MM) (DD) (YY) / (Limit to 2 spaces) ® City (Limit to 20 spaces) State / Zip Code Purchase Description of Material/Service Order No. If items are too numerous to be incorporated into the block below, and Date 6 Indicator-Statewide use Form AC 93 and carry total forward. Quantity Unit Price Amount . Payee Certification: 7 I certify that the above bill is just, true and correct; that no part thereof has been paid except as stated and that Total the balance is actually due and owing, and that taxes from which the State is exempt are excluded. Discount Payee's Signature In Ink Date Name of Company Net STATE COMPTROLLER'S PRE-AUDIT FOR AGENCY USE ONLY Merchandise Received % Title Certified For Payment I certify that this voucher is correct and just, and payment is approved, and the goods or services of rendered or furnished are for use in the performance of the official functions and duties of this agency. Net Amount Verified Date Authorized Signature Audited Page No. By Title Date Special Approval Liquidation Expenditure Cost Center Code Object Dept. Cost Center Unit Var Yr By (as Required) Accum Dept. Statewide Amount Orig. Agency PO/Contract Line F/P Check if Continuation 0SC form is attached. American LegalNet, Inc. www.USCourtForms.com