Fillable Printable General Services Administration Gsa Form 789
Fillable Printable General Services Administration Gsa Form 789
General Services Administration Gsa Form 789
GENERAL SERVICES ADMINISTRATION
STATEMENT, VOUCHER AND SCHEDULE OF WITHDRAWALS AND CREDITS
GSA Form 789 (Rev. 10-73)
DISBURSING OFFICE NO.
BUREAU VOUCHER NO. (Paying Office)
DATE
AGENCY
PAYMENT OR INQUIRY SHOULD REFER TO THE ABOVE DATE,
STATEMENT NUMBER, AGENCY, AND BILLED OFFICE CODES
FOR PROMPT HANDLING.
BILLED OFFICE
MO. DAY YR
PAGE
NO.
STATEMENT
NUMBER
DEPOSIT TO THE CREDIT OF ACCOUNT(S) SHOWN AND SEND ACCOMPLISHED C/D TO
OFFICE BILLED (Include ZIP Code)
AGENCY
REQUISITION NUMBER
TOTAL AMOUNT DUE
ON THIS STATEMENT
(The total amount due on this statement must be paid as rendered in
accordance with 7 GAO 2. 8.5 and FPMR Title 41 Chap. 101. Adjustments
if required will appear on subsequent statements.)
TO
(DISBURSING OFFICE AND SYMBOL PAYING OFFICE)
CERTIFICATE OF PAYING OFFICE FOR USE OF PAYING OFFICE
(DATE) (AUTHORIZED CERTIFYING OFFICER)
I certify that the items listed herein are correct and proper for payment from
the appropriation(s) designated.
PAID BY
CHECK NO.
7789-105
DATED C/D NO. DATED
WITHDRAW FROM
DEPARTMENT
BUREAU
REFERENCE
APPROPRIATION OR FUND
(Symbol Only)
AMOUNT
BUREAU
ADDRESS
ACT
GSA INVOICE
OR DOC. NO.
AMOUNT REMARKS
MO.
INV. DATE
DAY
or Send Remittance Payable to The General Services Administration accompanied by one copy of this GSA Form 789 , to
the Office indicated above. Adjustments are not to be requested or made for over or under charges of $10.00 or less per
Line Item (FPMR - A - 101-2.104(c).
PAID BY
