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AC 916 Rev. 3/98 SEE PROCEDURE MANUAL FOR INSTRUCTIONS STATE OF NEW YORK SPECIAL CHARGE VOUCHER Originating Agency Payee ID Interest Eligible Y/N Orig. Agency Code Payment Date OSC Use Only MM DD YY Additional Zip Code Voucher No* Liability Date Route Payee Amount MIR Date MM DD YY Payee Name Limit to 30 spaces IRS Code IRS Amount Stat. Type Statistic Indicator-Dept. Address Limit to 30 spaces Ref/Inv* No* Limit to 20 spaces Ref/Inv* Date Indicator-Statewide City Limit to 20 spaces Limit to 2 spaces State Zip Code DESCRIPTION OR REASON Total Number of Payees on this Voucher Total Amount of this Voucher STATE COMPTROLLER S PRE-AUDIT To the State Comptroller Please issue your warrant in favor of the above payee s and for the respective amounts listed* I certify that the above claim is correct in accordance with the provisions of the Applicable Statute that no part has been paid except as stated that the balance is actually due and that taxes from which the State is exempt are excluded* Signature in Ink Date CERTIFIED FOR PAYMENT OF TOTAL AMOUNT Verified Audited Title Expenditures Cost Center Code Dept. Cost Center Unit Object Var Yr Accum Liquidation Amount PO/Contract Line F/P Statewide Check if Continuation form is attached*. Agency Code Payment Date OSC Use Only MM DD YY Additional Zip Code Voucher No* Liability Date Route Payee Amount MIR Date MM DD YY Payee Name Limit to 30 spaces IRS Code IRS Amount Stat. Type Statistic Indicator-Dept. Address Limit to 30 spaces Ref/Inv* No* Limit to 20 spaces Ref/Inv* Date Indicator-Statewide City Limit to 20 spaces Limit to 2 spaces State Zip Code DESCRIPTION OR REASON Total Number of Payees on this Voucher Total Amount of this Voucher STATE COMPTROLLER S PRE-AUDIT To the State Comptroller Please issue your warrant in favor of the above payee s and for the respective amounts listed* I certify that the above claim is correct in accordance with the provisions of the Applicable Statute that no part has been paid except as stated that the balance is actually due and that taxes from which the State is exempt are excluded* Signature in Ink Date CERTIFIED FOR PAYMENT OF TOTAL AMOUNT Verified Audited Title Expenditures Cost Center Code Dept. Type Statistic Indicator-Dept. Address Limit to 30 spaces Ref/Inv* No* Limit to 20 spaces Ref/Inv* Date Indicator-Statewide City Limit to 20 spaces Limit to 2 spaces State Zip Code DESCRIPTION OR REASON Total Number of Payees on this Voucher Total Amount of this Voucher STATE COMPTROLLER S PRE-AUDIT To the State Comptroller Please issue your warrant in favor of the above payee s and for the respective amounts listed* I certify that the above claim is correct in accordance with the provisions of the Applicable Statute that no part has been paid except as stated that the balance is actually due and that taxes from which the State is exempt are excluded* Signature in Ink Date CERTIFIED FOR PAYMENT OF TOTAL AMOUNT Verified Audited Title Expenditures Cost Center Code Dept. Cost Center Unit Object Var Yr Accum Liquidation Amount PO/Contract Line F/P Statewide Check if Continuation form is attached*.

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