Homepage Fill in a Valid Massachusetts Payment Voucher Form
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The Massachusetts Payment Voucher form serves as a crucial document for vendors seeking reimbursement for goods or services rendered to state agencies. This form includes essential details such as the vendor's name and address, the total payment amount, and a breakdown of the services provided or goods delivered. Each section is meticulously designed to capture necessary information, including the document ID, accounting period, budget fiscal year, and payment reference number. Additionally, the form requires the vendor's certification, affirming that the goods were shipped or services rendered as specified. Compliance is paramount; thus, the signer must certify under penalties of perjury that all applicable laws and regulations governing public fund disbursements have been followed. The form also mandates the inclusion of various identifiers, such as the department or organization number and the project classification, ensuring accurate tracking and reporting of expenditures. Vendors must complete the shaded areas and direct any inquiries to the appropriate state organization, making the process streamlined and efficient for both parties involved.

Massachusetts Payment Voucher Example

PAYMENT VOUCHER INPUT FORM

Department/Organization Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Document ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trans

 

Dept

 

R/Org

Number

PV Date

 

Acctg Prd

 

Budget FY

PV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Action

(E)

 

 

Sch Pay Date

Off Liab Act

 

VENDOR'S CERTIFICATION

 

(M)

 

 

 

 

 

 

I certify that the goods were shipped or the service rendered

 

 

 

 

 

 

 

as set forth below

 

 

 

 

 

 

 

 

 

 

 

 

 

Ref Doc ID

 

 

 

 

 

------------------------------------------------

 

 

 

 

 

 

(Please Sign In Ink)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commonwealth of Massachusetts

Office of the Comptroller

Vendor Name and Address

Document Total

Payment Ref Number

Vendor Code

Emp

Reference Order

LN QTY

Description

Unit Price

Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reference Doc ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LN

Trans

Dept

R/Org

 

Number

 

LN

Dept

Approp

Sub

Org

S/Org

Obj

Prog

 

TY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Proj/Cl/Grc

Actv

RPTG

Fund

BS Acct

Payment Reference Number

 

Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSA#

 

Line#

 

Disc

 

 

 

Dates of Services

 

Quantity

Line Amount

 

 

 

I/D

P/F

 

 

 

 

 

 

 

 

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO THE COMPTROLLER OF THE COMMMONWEALTH OF MASSACHUSETTS:

I hereby certify under penalties of perjury that all laws of the Commonwealth governing disbursementsof public funds and the regulations thereof have been compLIED with and observed.

Prepared By:

 

Title:

 

Date:

 

 

 

 

 

Entered By:

 

Title:

 

Date

 

 

 

 

 

 

 

The undersigned authorized signatory approving this document certifies that this document and any attachments are accurate and complete and comply with all applicable general and special laws and regulations.

INSTRUCTIONS TO VENDORS

-Fill in shaded area

-Direct inquires to state organization

Page of

Phone #

Approved By:

 

Title:

 

Date:

 

 

Form Specs

Fact Name Description
Purpose The Massachusetts Payment Voucher form is used to request payment for goods or services provided to state agencies.
Governing Law This form is governed by the Massachusetts General Laws, Chapter 7, Section 22.
Vendor Certification Vendors must certify that the goods were shipped or services rendered as stated on the form, ensuring compliance with state regulations.
Submission Requirements The completed form must be signed in ink and submitted to the Comptroller of the Commonwealth of Massachusetts for processing.
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