EFTA00193104¶
U.S. Department of Justice¶
Washington, D.C. 20530¶
Request for Financial Information (Authorization, Purchase Order, Receiving Report)¶
| Service/Financial Records Provided: | Quantity | Unit Price | Amount | |
|---|---|---|---|---|
| Cost | Per | |||
| FOR PROMPT PAYMENT INCLUDE TAX LD. NUMBER. Please note that reimbursement cannot be made for the records pertaining to corporations or large partnerships of six or more. IMPORTANT: The DCIA Mandates the use of EFT/DD. In order to receive payment complete the attached EFT enrollment form. | 0.25 | Copy | ||
| 11.00 | Hour Clerical Tech | |||
| 17.00 | Hour Manger or Supervisor | |||
| Do not proceed with compliance: If cost will exceed $500 without prior approval of Budget Officer Lazaro Feliciano. Fax any request to (305) 530-7679 | ||||
| 12 Signature of Financial Institution Official: | 13 Date Signed: | Total Amount Claimed by Financial Institution | 0.00 | |
| Section C - Receiving Report | ||||
| 14 I certify that the articles and services listed were received: | 15 Date Received: | 17 Net to Financial Institution | ||
| 18 Right to Financial Privacy Act - Public Law 95-630 (12 U.S.C. 3401-3422) Request Parsuant To: (Check One Only) | OBJECT CLASS | 19 Signature of Approving Official: | ||
| □ 3404 Customer Authorization | 2540 | 20 Accounting Classification Code | ||
| □ 3405 Administrative Subpoena or Surveys | 2541 | FV PC 1 2 3 4 5 PROJ | ||
| □ 3406 Search Warrant | 2542 | |||
| □ 3407 Judicial Subpoena | 2543 | |||
| □ 3408 Formal Written Request | 2544 | 21 Schedule and Voucher Number: DC# | ||
| □ 3413 I Grand Jury Subpoena | 2545 | |||
| □ 3414 Special Procedures | 2546 | |||
FORM OBD-211 APR. 84¶