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CLAIM -- VOUCHER Name of Business Unit personnel who prepared this claim. State Form 11294 R7 / 9-09 Approved by Auditor of State 2009 Approved by State Board of Accounts 2009 Name Telephone number CDBG Accountant 232-xxxx Business Unit Number Lt Governor s Office ENCOMPASS Voucher Number Invoice Number To be completed by CDBG Accountant Invoice Date month day year Invoice Amount Grant Number Name of Vendor Date submtted Total Amount of this claim Address number and street Grantee Name City Town or County Grantee s Street Address or P. O. Box ENCOMPASS Vendor Number Address city state and ZIP code Grantee s Federal Identification Number REMIT 00X Account Grantee s City State and Zip AREA BELOW TO BE COMPLETED BY BUSINESS UNIT. Date Line Submitted 04B Amount Bud Ref 20 000. 00 Fund Account Department Program Project Activity Handling Code Line Description Grant Administration Sewer Construction Engineering GROSS AMOUNT Furnished to name of business unit I certify that this claim is correct and valid and is a proper charge against the chartfields indicated* Authorized Signature of Business Unit Date month day year Pursuant to the provisions and penalties of Indiana Code 5-11-10-1 I hereby certify that the foregoing Fund and Account is just and correct that the amount claimed is legally due after allowing all just credits and that no part of the same has been paid* Signature of Vendor. O. Box ENCOMPASS Vendor Number Address city state and ZIP code Grantee s Federal Identification Number REMIT 00X Account Grantee s City State and Zip AREA BELOW TO BE COMPLETED BY BUSINESS UNIT. Date Line Submitted 04B Amount Bud Ref 20 000. 00 Fund Account Department Program Project Activity Handling Code Line Description Grant Administration Sewer Construction Engineering GROSS AMOUNT Furnished to name of business unit I certify that this claim is correct and valid and is a proper charge against the chartfields indicated* Authorized Signature of Business Unit Date month day year Pursuant to the provisions and penalties of Indiana Code 5-11-10-1 I hereby certify that the foregoing Fund and Account is just and correct that the amount claimed is legally due after allowing all just credits and that no part of the same has been paid* Signature of Vendor.

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