VENDOR INVOICE FOR GOODS OR SERVICES
RENDERED TO THE STATE OF CONNECTICUT
CO - 17 REV. 10/2010

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

(1) BUSINESS UNIT NAME

 (2) BUSINESS UNIT NO.

(3) INVOICE  NO.

(4) INVOICE AMOUNT

(5) DOCUMENT DATE

(6) INVOICE DATE

(7) ACCOUNTING DATE

(8) RPT. TYPE

(9) VENDOR FEIN/SSN ID / ADDRESS CODE

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

(10)

 (11) 

VOUCHER NO.

PAYEE:

PAYEE:

ADDRESS:

ADDRESS:

ADDRESS:

(12)  

VOUCHER DATE  

PREPARED BY 

 CITY:

STATE :

          COUNTRY:

ZIP CODE :

(13)  VENDOR  COMMENTS

(14)

(15)

(16)

(17)

(18)

GIVE FULL DESCRIPTION OF GOODS AND / OR SERVICES 

QUANTITY

(TO BE COMPLETED BY VENDOR)

UNITS

UNIT PRICE

AMOUNT

BUSINESS UNIT USE ONLY

(19)

(20) 

(21)

(22)

(23)

(24)

(25)

(26)

(27)

(28)

(29)

 QUANTITY

 DEPARTMENT

  AMOUNT

FUND

SID

PROGRAM

ACCOUNT

  PROJECT/
    GRANT

   CHARTFIELD 
             1

BUDGET

CHARTFIELD
           2 

 REFERENCE

 (30)    DEPARTMENT  NAME  AND ADDRESS

(31)  PO NO.

(32) COMMODITIES RECEIVED OR SERVICES RENDERED - SIGNATURE

(33)  PO BUSINESS  UNIT

(34) RECEIVING REPORT NO.

(35) DATE(S) OF RECEIPT(S)

SHIPPING INFORMATION

(36) DATE SHIPPED

(37) FROM - CITY / STATE

(38) VIA - CARRIER

(39) F.O.B.