1. DEPARTMENT 2. VOUCHER NUMBER
MILITARY PAY VOUCHER
IDENTIFICATION AND CERTIFICATION
3. ATTACHMENT 5. PAYROLL NUMBER
Pages
4. ORGANIZATION AND LOCATION
6. PURPOSE OF PAYMENT
7. PAID BY
(Brief Stamp)
I CERTIFY this voucher is correct and proper for payment from the appropriation and/or fund indicated below.
TO:
8. TYPED NAME OF DISBURSING OFFICER 9. DSSN 10. SIGNATURE OF DISBURSING OFFICER OR DEPUTY
As Agent Officer to the above Disbursing Officer, I CERTIFY the amounts shown on the attached money lists
have been paid by me to members listed thereon after proper identification.
11. SIGNATURE OF AGENT OFFICER 12. DATE PAID
APPROPRIATION CHARGES
13. APPROPRIATION 14. AMOUNT
$
15. PREPARED BY 16. REVIEWED BY
17.
TOTAL $
PAYMENT DATA
CHECK PAYMENT
CASH PAYMENT
18. AMOUNT
20. AMOUNT
19. PAID BY CHECK NUMBERS
TO INCL
21. I acknowledge receipt of cash payment in amount stated.
SIGNATURE OF PAYEE (For an individual cash payment)
DD FORM 117, SEP 77
EDITION OF 1 MAY 74 WILL BE USED UNTIL EXHAUSTED.
FORM APPROVED BY COMPTROLLER GENERAL, U.S.
11 FEB 72
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