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CLAIM VOUCHER -- FOOD STAMPS
State Form 45636 (R6 / 4-09) / IMP 2641B Approved by State Board of Accounts, 2002
INSTRUCTIONS: This agency is requesting disclosure of your Social Security number in accordance with IC 4-1-8-1. VENDOR INFORMATION
Document number Vendor name Address (number and street) Date (month, day, year) Agency name
AGENCY INFORMATION
Division of Family Resources, FSSA - IMPACT (FS)
Agency number
500
Social Security number or
0Federal I.D. number
0City, state and ZIP code
Vendor number
DATE
AMOUNT
FUND
OBJECT
AREA BELOW TO BE COMPLETED BY AGENCY CENTER LOAN / INV / NBR QTY
UNIT
DESCRIPTION
2250
572700
150000
NO
Name of participant
County number
Case number
Social Security number
SERVICE CODE 01
Services for:
Thru:
Prepared by: Date prepared (month, day, year) Telephone number
0.00 Mileage: Number of Miles ____________ X .10 = $ _______________
or $2.00 per day, whichever is higher $ _______________
02 03 04 05 07
Bus Tokens Gas Coupons Vehicle Expenses Clothing, Uniforms, and Shoes Training / Tuition / GED Fees / Books
$ $ $ $ $
(
Comments:
)
(Reason for request)
NOTE: Service Codes 01 through 10 cannot exceed $100.00 per month per participant, except training / tuition / GED fees which are not subject to this limit.
Division of Family Resources, FSSA I certify that this claim is correct and valid and is a proper charge against the State Agency, Fund and Center indicated.
Authorized Signature of Local Office Date signed (month, day, year)
GROSS AMOUNT: $
Furnished to: (Name of State Agency)
Pursuant to the provisions and penalties of IC 5-11-10-1, I hereby certify that the foregoing 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 Date signed (month, day, year)
DISTRIBUTION: White - Return for payment with original invoice; Canary - Vendor copy; Pink - Case file