CREDIT CARD PURCHASE TRANSACTION / Funding Reservation Number
I. PURCHASE APPROVAL: The items specified are considered in the Agency's best interests, meet the minimum need, and are approved for purchase: / Signature
SIGNATURE OF AUTHORIZING OFFICIAL / Office Control Number:
INSTRUCTIONS TO CARDHOLDERS: Complete this form for each purchase charged to an Agency VISA credit card. Establish funds availability prior to executing a transaction. Do not exceed authorized single purchase limit. / Assigned Cardholder:
Quantity / II. DESCRIPTION OF ITEM
NOTE: The credit card may not be used for purposes involving travel, entertainment, or meals. This includes transactions involving any of the following: Airlines, Hotels. / OBJ.
CLASS / COST
EACH / TOTAL
COST
0.00
0.00
0.00
0.00
0.00
SPECIAL INSTRUCTIONS: / TAX
FREE / Delivery Charge >
Amount from
continuation
page >
Signature of Cardholder: / Date: / Total Cost >
II.
VENDOR
INFORMATION / Vendor Name and Address
* / Deliver to
Client Office
Warehouse / Other
Deliver Via
Parcel Post
UPS / Other
Telephone Number (include area code) / Delivery Date
IV.
FUNDING
INFORMATION / Budget
Plan Code > / Project Number
Appropriation
Number > / Obligation
Number >
V.
RECEIPT / Received By: / Office: / Building:
Room Number:
Date Received: / Received by Client:
VI. FUNDING
ADJUSTMENT / Deobligation Amount: / Date Completed:
VII.
FORM
DISTRIBUTION / Cardholder - 1 Original (Signed) M/AS/PMD - 1 Copy (If Delivered to Warehouse) M/FM/A - 1 Original (Signed) Bureau/Office - As Required
M/FM/CMP - 1 Copy
AID 530-3 (3/95)
PREVIOUS PAGE TOTAL:Quantity / II. DESCRIPTION OF ITEM
NOTE: The credit card may not be used for purposes involving travel, entertainment, or meals. This includes transactions involving any of the following: Airlines, Hotels. / OBJ.
CLASS / COST
EACH / TOTAL
COST
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total Cost >
AID 530-3 (10/95)