| OLO/Department: |
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Agency Contact: |
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| FLAIR Contract #: |
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Telephone #: |
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| Agency Contract #: |
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| Contractor/Vendor/Payee: |
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| Original Contract Amount: |
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Total Contract Amount: |
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Contract Type: |
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| Contract Start Date: |
Contract End Date: |
| Contract Last Signed Date: |
Advanced Funded: |
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| METHOD OF PROCUREMENT: |
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| AGENCY REFERENCE #: |
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| Invoice Number: |
Invoice Period: |
| Total Amount of Previous Payments: |
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| CONTRACT MANAGER CERTIFICATION: |
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I certify, by evidence of my signature, the information on this form is true and correct; the goods and services have been satisfactorily
received and payment is now due. I understand that the office of the State Financial Officer reserves the right to require additional
documentation and/or to conduct periodic post-audits of any agreements.
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| Contract Manager Name printed: |
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| Contract Manager Signature: |
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Date: |