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Get Ac 1171 Fillable

SEE INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING AC 1171 Rev. 10/96 STATE OF NEW YORK 1 Originating Agency Orig. Agency Code NYS Dept. of Environmental Conservation Payment Date MM DD YY Interest Eligible Y/N 09000 No OSC Use Only Additional 2 Payee ID Voucher No. STATE AID VOUCHER Liability Date 3 Zip Code Route MM DD YY Payee Amount 4 Payee Name Limit to 30 spaces IRS Code IRS Amount Stat. Agency Code NYS Dept. of Environmental Conservation P.

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