VENDOR INVOICE FOR GOODS OR SERVICES
RENDERED TO THE STATE OF CONNECTICUT
CO - 17 REV. 7/03 (STOCK NO 102-01)

STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
ACCOUNTS PAYABLE DIVISION

VENDOR:

PLEASE COMPLETE THIS FORM AND SEND IT TO THE
DEPARTMENT BILLING ADDRESS SHOWN ON THE PURCHASE ORDER

VENDOR / PAYEE: FIELDS 9,10,14 and 18 ARE MANDATORY FOR PAYMENT

(1) BUSINESS UNIT NAME

(5) DOCUMENT DATE

(3) INVOICE NO.

(4) INVOICE AMOUNT

(10)

(6) INVOICE DATE

(7) ACCOUNTING DATE

(8) RPT. TYPE

(9) VENDOR FEIN/SSN ID / ADDRESS CODE

SHIPPING INFORMATION

(38) DATE SHIPPED

(39) FROM - CITY / STATE

(40) VIA - CARRIER

(41) F.O.B.

(36) RECEIVING REPORT NO.

(37) DATE(S) OF RECEIPT(S)

(35) COMMODITIES RECEIVED OR SERVICES RENDERED - SIGNATURE

PAYEE:
 
PAYEE:
 
ADDRESS:
 
ADDRESS:
 
ADDRESS:

STATE :

ZIP CODE :

(13) VENDOR COMMENTS

(14)

GIVE FULL DESCRIPTION OF GOODS AND / OR SERVICES

(15)

(16)

(17)

(18)

QUANTITY

UNITS

UNIT PRICE

AMOUNT

(19)
 

(20)

(21)

(26)

ACCOUNT

(28)

BUSINESS UNIT USE ONLY

DEPARTMENT

QUANTITY

GL UNIT

(22)

PROJECT/
GRANT

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REFERENCE

(32) DEPARTMENT NAME AND ADDRESS

(2) BUSINESS UNIT NO.

(24)

(29)

(30)

(31)

(23)

FUND

DATE

AMOUNT

(25)

SID

(27)

PROGRAM

CITY:

COUNTRY:

BUDGET

BUDGET

(12)

VOUCHER DATE _________________

(TO BE COMPLETED BY VENDOR)

(33) PO NO.

(34) PO BUSINESS UNIT

(11)

VOUCHER NO.

PREPARED BY ____________________

STATE

STATE

STATE

STATE

STATE

STATE

STATE

STATE

STATE

CHARTFIELD
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