Voucher Number U. S. Department of State PUBLIC VOUCHER FOR LANGUAGE SERVICES Payee's Name and Bank Information NOTE: Submit all Address/Banking Information changes with voucher. Title: Conference Interpreter Name (Last, First, MI.) Seminar Interpreter SSN Consecutive Interpreter Bank Name ELO/COURT Routing Number (ABA) Testing and Screening Account Number Translating Services Account Type Date Voucher Prepared (mm-dd-yyyy) Contract Number (BOA) Job Number (Checking) (Savings) or Reviewer/Typist/Others Home Phone Number PERIOD OF SERVICE (mm-dd-yyyy) FROM NATURE OF SERVICES OR ARTICLES (Enter description and other information) TO NUMBER OF DAYS OR WORDS UNIT PRICE PER COST AMOUNT (Dollars and Cents) TOTAL FOR INTERPRETERS ONLY: Please specify Agency or Program for which work was performed PAYMENT: (check one) I certify that the above charges are correct to the best of my knowledge; that I have not received payment or credit for them; that the services were rendered as stated, solely by the undersigned, and in accordance with the highest professional standards. (Check one) Final Partial of *Payment due within 30 days* Payee's Signature PAYEE MUST NOT USE THE SPACE BELOW Date Goods/Services Received/Accepted (mm-dd-yyyy) Office of Language Services SA-1, 14th Floor 2401 E Street, NW Washington, DC 20522 I certify this account is correct and proper for payment. Signature of Authorizing/Receiving Official Printed Name of Receiving Official Phone Number ACCOUNTING CLASSIFICATION Paid By: Check Number Dated (mm-dd-yyyy) On (Name of Bank) PRIVACY ACT STATEMENT This information requested on this form is required under the provisions of 31 U.S.C. 82b AND 82c, for the purpose of disbursing Federal money. The information requested is to identify the particular creditor and the amount to be paid. Failure to furnish this information will hinder discharge of the payment obligation. DS-3023 02-2006 Original - RM - Action Office Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com Voucher Number U. S. Department of State PUBLIC VOUCHER FOR LANGUAGE SERVICES Payee's Name and Bank Information NOTE: Submit all Address/Banking Information changes with voucher. Title: Conference Interpreter Name (Last, First, MI.) Seminar Interpreter SSN Consecutive Interpreter Bank Name ELO/COURT Routing Number (ABA) Testing and Screening Account Number Translating Services Account Type Date Voucher Prepared (mm-dd-yyyy) Contract Number (BOA) Job Number (Savings) or (Checking) Reviewer/Typist/Others Home Phone Number PERIOD OF SERVICE (mm-dd-yyyy) FROM NATURE OF SERVICES OR ARTICLES (Enter description and other information) TO NUMBER OF DAYS OR WORDS UNIT PRICE PER COST AMOUNT (Dollars and Cents) TOTAL FOR INTERPRETERS ONLY: Please specify Agency or Program for which work was performed PAYMENT: (check one) I certify that the above charges are correct to the best of my knowledge; that I have not received payment or credit for them; that the services were rendered as stated, solely by the undersigned, and in accordance with the highest professional standards. (Check one) Final Partial of *Payment due within 30 days* Payee's Signature PAYEE MUST NOT USE THE SPACE BELOW Date Goods/Services Received/Accepted (mm-dd-yyyy) Office of Language Services SA-1, 14th Floor 2401 E Street, NW Washington, DC 20522 I certify this account is correct and proper for payment. Signature of Authorizing/Receiving Official Printed Name of Receiving Official Phone Number ACCOUNTING CLASSIFICATION Paid By: Check Number Dated (mm-dd-yyyy) On (Name of Bank) PRIVACY ACT STATEMENT This information requested on this form is required under the provisions of 31 U.S.C. 82b AND 82c, for the purpose of disbursing Federal money. The information requested is to identify the particular creditor and the amount to be paid. Failure to furnish this information will hinder discharge of the payment obligation. DS-3023 Copy 1 - A/OPR/LS Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com Voucher Number U. S. Department of State PUBLIC VOUCHER FOR LANGUAGE SERVICES Payee's Name and Bank Information NOTE: Submit all Address/Banking Information changes with voucher. Title: Conference Interpreter Name (Last, First, MI.) Seminar Interpreter SSN Consecutive Interpreter Bank Name ELO/COURT Routing Number (ABA) Testing and Screening Account Number Translating Services Account Type Date Voucher Prepared (mm-dd-yyyy) Contract Number (BOA) Job Number (Savings) or (Checking) Reviewer/Typist/Others Home Phone Number PERIOD OF SERVICE (mm-dd-yyyy) FROM NATURE OF SERVICES OR ARTICLES (Enter description and other information) TO NUMBER OF DAYS OR WORDS UNIT PRICE PER COST AMOUNT (Dollars and Cents) TOTAL FOR INTERPRETERS ONLY: Please specify Agency or Program for which work was performed PAYMENT: (check one) I certify that the above charges are correct to the best of my knowledge; that I have not received payment or credit for them; that the services were rendered as stated, solely by the undersigned, and in accordance with the highest professional standards. (Check one) Final Partial of *Payment due within 30 days* Payee's Signature PAYEE MUST NOT USE THE SPACE BELOW Date Goods/Services Received/Accepted (mm-dd-yyyy) Office of Language Services SA-1, 14th Floor 2401 E Street, NW Washington, DC 20522 I certify this account is correct and proper for payment. Signature of Authorizing/Receiving Official Printed Name of Receiving Official Phone Number ACCOUNTING CLASSIFICATION Paid By: Check Number Dated (mm-dd-yyyy) On (Name of Bank) PRIVACY ACT STATEMENT This information requested on this form is required under the provisions of 31 U.S.C. 82b AND 82c, for the purpose of disbursing Federal money. The information requested is to identify the particular creditor and the amount to be paid. Failure to furnish this information will hinder discharge of the payment obligation. DS-3023 Copy 2 - Contractor Copy Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com