EFTA00220999.pdf

U.S. Department of Justice Request for (Authorization, Washington, D.C. 20530 Purchase Order, Receiving Report) This rum %ban only be wed when requesting I Purelune Order Numberil/CNN: 11011.1960 )f individuals and partnership, of live or fewer individuals. 2 Date thder Prepared: 08102/2006 3Case Number: (Optional) FOJ 05-02(WPB) NO.051-01(O1.1%01) Section A • Authorisation asd Purchase Order 4 Names and Address of Mtn. Research Dept. Hoover. AL 35243 5 Deliver To: Special Agent S Federal Bureau of Investigatioa Florida 33401. Tel.: 6 Return Date WHIP2806 7 Remarks: FOR REIMBURSEMENT PLEASE RETURN THIS FORM, TIE RECORD OF SERVICES, ANDA COPY °ETRE SUBPOENA . 8 Name of ReqUestOr: (Type or Print) 9 Telephone Number: ID Date of request: AUSA 01102/2006 Section B - Invoice rvo l'aynIcnt :than tic made Unless t.Xplames Ate ucrosnu nen • WI- 5m sour roan to 11 SeraCe Plus idetl Quantity Unit Price Amount Cost Per Please note that reimbursement cannot be made for the records 0.25 Copy 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. 11.00 How Clerical Tech 17.00 How Manager or Supervisor )o not proceed with compliance : if cost will exceed $300 without prior approval of Assistant U.S. Attorney/Budget Officer. PLEASE REFERENCE THE ABOVE DCN# ON YOUR INVOICE FOR PAYMENT. 12a Signature of 12b Phone o Official: 13 Date Signed: Total Amount Claimed By Section C- Receiving Report 6 Disallowance (See Attached) 14 I certify that the articles and services listed were received: 15 Dale Received: 7 N., 18 Right to Financial Privacy Act • Public Law 95.630 19 Signature o Approval Official: 20 Accounting Classification Code (12 U.S.C. 3401.3422) Request Pursuant To: (Check One (Mfy) OBJECT FY FC I 2 3 4 5 PROJ SECTION CLASS LI 3404 Customer Authorization 2540 21 Schedule and Voucher Number: DC# -7 2 3405 Administrative Subpoena or Summons 2541 13 3406 Search Warrant 2540 4 3407 Judicial Subpoena 2540 -75 3408 Formal Written Request 2540 3413 I Grand Jury Subpoena 2545 T7 3414 Special Procedures 2540 22 Remarks: REI Funds Available EFTA00220999  T9 T1D Pam OB1)211 T11 T12 APR 84 This form woe electronically produced by Flue Federal Forms. Inc. Page I col3 GENERAL This is a multi-purpose form designed to serve as an Authorization• Purchase Order, Itemized Invoice, receiving Report and Payment voucher in conjunction with "requests for " pursuant to the Right to Financial Privacy Act of 1978, P.L. 95-630. Title XL, 12 U.S.C. 3415. NOTE: Payments under this purchase order will be due on the 30 0, calendar day after the date of actual receipt of a proper invoice in the office designated to receive the invoice. The Prompt Payment Act. Public Law 97-177, 96 Stat. 85 (31 U.S.C. 180). is applicable to payments under this purchase order and requires the payment to contractors of interest or overdue payments and improperly taken discounts. Determination of interest due will be made in accordance with the provision of the Prompt Payment Act and the Office of Management and Budge Circular A-125. PREPARATION INSTRUCTIONS ITEM 1 - A Purchase Order Number will be preprinted on each form. This number will be used for reference purposes on any correspondence relating to this specific request for ITEM 2 - Self explanatory. ITEM 3 - This block may be used Co identify the specific case for which the is required. This block may be let blank. SECTION A - AUTHORIZATION AND PURCHASE ORDER (To be completed by the requesting official). ITEM 4 - Enter the name and mailing address of the being requested to furnish ITEM 5 - Enter the and address to which the is to be sent by the This will normally be the name and the address of the requesting official. ITEM 6 - Enter the date the is required. ITEM 7 - Include, if appropriate. any pertinent information related to the purchase order not provided for elsewhere on the form. ITEM 8, 9 and 10 - Self-explanatory. SECTION B - INVOICE (To be completed by the ITEM I I - Self-explanatory. Completion of this block constitutes an itemized bill or invoice for reimbursement for the costs incurred in providing the information requested. The DCIA Mandates the use ofEFT/DD. In order to receive payment complete the attached EFT enrollment Form. ITEM 12 and 13 - Self-explanatory. SECTION C - RECEIVING REPORT (To be completed by the requesting official, when the requested has been delivered). ITEM 14 and 15 - Self-explanatory. ITEM 16 - This block should be used to reflect any differences between the amount claimed by the and the correct amount to be reimbursed. Differences may result form computation errors, or failure of the to deliver information requested. ITEM 17 - Enter the amount certified Co be proper for payment. ITEM 18 - Check the box which identifies the appropriate procedure authorized by the Act, which necessitates the request for ITEM 19 and 20 - These blocks must be signed and dated by an official of the organization whose funds will be charged. His or her signature constitutes a statement that the records to which the invoice refers were required for official business and were provided by the in accordance with the ordering instrument. ITEM 21 - The Schedule and Voucher Number will be entered by the office which actually schedules the approved amount for payment by the Treasury Department. ITEM 22 - Enter, if appropriate, any data not provided for elsewhere on the receiving report, such as, reasons for any claim amounts disallowed. FORM OBD-21I APR. 84 Page 2 of3 VENDOR ELECTRONIC FUNDS TRANSFER (EFT) ENROLLMENT FORM Please comply to this information if you have not done so already PAYEE/COMPANY INFORMATION: Vendor Company Name: Address: Taxpayer ID Number ontact Person Name 'Telephone Number EFTA00221000 E-mail Address (If you would like to be notified via e-mail) INFORMATION: Bank Name Bank Address Bank Phone Number Nine Digit ABA Routing Transit Number Type of Account (Checking or Saving) Depositor Account Number Signature of Vendor's Authorizing Official Name & Title of Authorizing Official Please Return or Fax to: U.S. Attorney's Office Southern District of Florida Attention: Fax Number: The Debt Collection Improvement Act of 1996 requires that payments made by the Federal government, including vendor payments, must be made by electronic funds transfer (EFT). A benefit of receiving payments by EFT is that your funds are directly deposited to your account at a and are available to you on the date of payment. If you have questions regarding the delivery of the remittance information. please contact the where your account is held. If you have any questions on the completion of this form, please contact . at FORM OBO.211 APR. gl Page 3 ol'3 TEXT BOXES TI 17 T3 T4 15 To T7 TR EFTA00221001 T — 9Date TIO MOudget Officer T12 EFTA00221002