Vendor No.			Check No.
Town of Southold, New York - Payment Voucher
Vendor Tax ID Number or Social Security Number				Vendor Address					Entered by
Vendor Name									Audit Date
Vendor Telephone Number
									Town Clerk
Vendor Contact
Invoice	Invoice	Invoice		Net	Purchase Order
Number	Date	Total	Discount	Amount Claimed	Number	Description of Goods or Services		General Ledger Fund and Account Number
Payee Certification					Department Certification
The undersigned (Claimant) (Acting on behalf of the above named claimant)					I hereby certify that the materials above specified have been received by me
does hereby certify that the foregoing claim is true and correct, that no part has					in good condition without substitution, the services properly
been paid, except as therein stated, that the balance therein stated is actually					performed and that the quantities thereof have been verified with the exceptions
due and owing, and that taxes from which the Town is exempt are excluded.					or discrepancies noted, and payment is approved.
Signature_________________________  Title ___________________________					Signature____________________________________________
Company Name                                                       Date___________________					Title                                                              Date _________________